Tissue plasminogen activator-assisted vitrectomy for submacular hemorrhage due to age-related macular degeneration

Abstract

Purpose:The purpose of this study was to evaluate the treatment efficacy of vitrectomy combined with subretinal recombinant tissue plasminogen activator (r-tPA) and factors affecting visual improvement in patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (nAMD).Materials and Methods:Medical records of 17 consecutive patients diagnosed with SMH secondary to nAMD were retrospectively reviewed. The initial surgical procedure involved a 23-gauge transconjunctival vitrectomy, subretinal r-tPA application through a self-sealing inferior retinotomy, and sulfur hexafluoride gas for tamponade in all patients. The duration, size, and thickness of the hemorrhage and the pre- and post-operative visual acuity (VA) using a Snellen chart were recorded. VA was converted to logMAR for statistical analysis.Results:The average duration and size of the SMH were 12.8 ± 18.2 days and 8.6 ± 5.3 disc areas, respectively. The mean follow-up time was 16.9 ± 4.7 months. A statistically significant visual improvement was found when comparing initial VA with postoperative best-corrected VA (BCVA) and final BCVA (Wilcoxon rank test, P ≤ 0.01). There was no significant correlation between the size of the hemorrhage and postoperative BCVA and final BCVA (Spearman's rho test). There was no statistically significant correlation between the initial VA and postoperative BCVA and final BCVA (Spearman's rho test). There was no significant correlation between the duration of hemorrhage and postoperative BCVA and final BCVA (Spearman's rho test). The preoperative thickness of hemorrhage (747.5 ± 30 μm) was not correlated with postoperative BCVA or final BCVA (Pearson's test).Conclusions:Vitrectomy combined with subretinal r-tPA injection and gas tamponade is an effective surgical intervention to preserve VA in selected patients with apparent SMH.

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.…”

“…Techniques consisting of vitrectomy and direct subretinal removal of the SMH have been found ineffective. With the increasing use of tPA, pneumatic displacement techniques have become preferred methods [8], [9], [10], [11], [12], [13], [14], [15]. Vitrectomy-based methods have been preserved for large SMHs, whereas intravitreal-injection based methods were used for limited SMHs [10], [11], [12], [13], [14], [15].…”

“…With the increasing use of tPA, pneumatic displacement techniques have become preferred methods [8], [9], [10], [11], [12], [13], [14], [15]. Vitrectomy-based methods have been preserved for large SMHs, whereas intravitreal-injection based methods were used for limited SMHs [10], [11], [12], [13], [14], [15]. Recently in a randomized clinical trial, 4 surgical treatment has been compared to observation [8], [9], [10], [11], [12], [13].…”

“…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.…”