Hemorrhagic Age-Related Macular Degeneration Managed With Vitrectomy, Subretinal Injection of Tissue Plasminogen Activator, Gas Tamponade, and Upright Positioning

Abstract

In patients with hemorrhagic neovascular AMD, treatment with vitrectomy, subretinal tPA injection, gas tamponade, and upright positioning was associated with better visual outcomes than those reported for patients with untreated disease.

Five-year Outcomes of Ranibizumab in Neovascular Age-related Macular Degeneration: Real Life Clinical Experience

“…Neovascular age-related macular degeneration (nAMD) is a major cause of vision loss among the elderly population in Western countries [ 1 2 ]. Before the era of anti-vascular endothelial growth factor treatment, visual loss prevention was only achieved in a limited number of patients despite the use of different treatment modalities [ 3 4 5 6 7 ]. Bevacizumab, ranibizumab, and finally aflibercept treatments have led to conservation of baseline visual acuity (VA) in the vast majority of patients and significantly increased VA in approximately one-third of patients [ 8 9 10 11 12 ].…”

Submacular hemorrhage secondary to age-related macular degeneration managed with vitrectomy, subretinal injection of tissue plasminogen activator, hemorrhage displacement with liquid perfluorocarbon, gas tamponade, and face-down positioning

“…To date, various surgical techniques and pneumatic methods have been investigated for manipulating the SMH and displacing it [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. Techniques consisting of vitrectomy and direct subretinal removal of the SMH have been found ineffective.…”

“…In patients diagnosed with nAMD limited to one eye, neovascular lesions associated by any amount of hemorrhage were found to develop in the other eye in 19% during 4 years of follow up 6 . As visual outcomes of SMH are usually devastating, several treatment options have been evaluated for its treatment including intravitreal injection of gases and tissue plasminogen activator (tPA), vitrectomy with or without intravitreal/subretinal tPA injection and pneumatic displacement of the hemorrhage [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. A consensus on the best approach to therapy has not yet emerged 8 .…”

“…A consensus on the best approach to therapy has not yet emerged 8 . Usually small hemorrhages are managed with intravitreal anti-vascular endothelial growth factor (Anti-VEGF) and gas/tPA injections, larger and thicker hemorrhages are managed with vitrectomy, intravitreal/subretinal tPA injection and pneumatic displacement, and massive hemorrhages require subretinal surgery [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. In a multicenter randomized study, 4 patients who underwent surgery with or without tPA for hemorrhagic nAMD did not have better visual outcomes than patients who did not undergo surgery.…”

The role of indocyanine green angiography imaging in further differential diagnosis of patients with nAMD who are morphologically poor responders to ranibizumab in a real-life setting

“…1,2 Before the era of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, only prevention of visual loss might have been achieved in a limited number of patients despite the use of different treatment modalities. [3][4][5][6][7][8] Bevacizumab, ranibizumab, and finally aflibercept have led to the conservation of the baseline visual acuity (VA) in the vast majority of the patients and have given the chance of increasing VA significantly in approximately one third of the patients. [9][10][11][12] Multicenter studies have shown that ranibizumab is effective in the prevention of VA loss in up to 95% of the patients, and an improvement in VA can be achieved in up to 40% of the patients.…”