Long-term outcome of subretinal coapplication of rtPA and bevacizumab followed by repeated intravitreal anti-VEGF injections for neovascular AMD with submacular haemorrhage

Abstract

The operation effectively displaces small and large SMHs. In the long-term, a predominantly visual acuity-driven re-treatment regimen puts the initial functional improvement at risk. More sensitive re-treatment parameters may help to improve long-term functional outcome.

Vitrectomy with subretinal tissue plasminogen activator and ranibizumab for submacular haemorrhages secondary to age-related macular degeneration: retrospective case series of 45 consecutive cases

“…9,10 A recent review by Stanescu-Segall et al 20 summarises the findings of these previous studies. To date, there is no consensus on the optimal management for patients presenting with this severe complication of nAMD.…”

“…10 Random effect meta-analysis showed that the incidence of RPE rips, macular hole, and retinal detachments is ∼ 2.3% (95 CI 0-5.5%) for each of these complications in this procedure.…”

“…We used a 23G cannula with a retractable 41G tip (Dutch Ophthalmic Research Center (DORC), Zuidland, The Netherlands), connected by tubing to a tuberculin syringe containing ∼ 0.5-0.7 ml of rtPA 125 μg/ml and 0.06 ml of Ranibizumab 10 mg/ml, using the technique previously described by Treumer, Hillenkamp, and colleagues. [9][10][11]15 The 41G tip was inserted into the subretinal space, and the assistant slowly injected the contents of the syringe, creating a local retinal detachment encompassing the haemorrhage. The total volume infused varies from 0.5 to 0.75 ml with larger volumes for larger haemorrhages.…”

“…A number of interventions have been proposed, including intravitreal anti-VEGF alone, 5,6 intravitreal anti-VEGF combined with intravitreal gas and/or recombinant tissue plasminogen activator (rtPA), 7,8 and vitrectomy with subretinal rtPA and anti-VEGF. 9,10 One retrospective comparative case series suggested that subretinal rtPA was more effective than intravitreal rtPA. 11 Some trials of anti-VEGF agents specifically excluded eyes with large haemorrhages.…”

Intravitreal anti-vascular endothelial growth factor monotherapy for large submacular hemorrhage secondary to neovascular age-related macular degeneration

“…For instance, in the Submacular Surgery Trial (SST), 440% of eyes exhibited lesion sizes larger than 16 DAs, and improvement in visual acuity by three lines or greater during 6 months was only achieved in 10% of eyes in the observation group and 11% of eyes in the surgery group. 10 In another investigation of patients with relatively small SMH areas, Treumer et al 16 reported that 12 of 26 eyes (46.1%; mean baseline hemorrhage area = 4.5 DA; mean follow-up time = 17 months) had BCVA improvements of ≥ 3 lines Figure 1 Changes in mean best-corrected visual acuity (BCVA) and mean central foveal thickness in eyes with large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) after treatment. The mean BCVA showed significant improvements during the follow-up period (a), and the mean central foveal thickness (b) also showed significant improvements during the follow-up period (*Po0.05).…”