Elsevier

Ophthalmology

Volume 122, Issue 1, January 2015, Pages 123-128
Ophthalmology

Original article
Displacement of Submacular Hemorrhages in Age-Related Macular Degeneration with Subretinal Tissue Plasminogen Activator and Air

https://doi.org/10.1016/j.ophtha.2014.07.027Get rights and content

Objective

To study the anatomic and visual outcomes of a surgical procedure in which tissue plasminogen activator and air are injected subretinally to displace massive submacular hemorrhages secondary to age-related macular degeneration.

Design

Prospective, consecutive, interventional case series.

Participants

Thirteen consecutive patients (13 eyes) with massive submacular hemorrhages secondary to age-related macular degeneration.

Intervention

The surgical procedure consisted of a 25-gauge vitrectomy and submacular injection of tissue plasminogen activator (25 μg) and 0.4 ml air with a microneedle having an outer diameter of 50 μm. The procedure was followed by having the patient remain in the prone position overnight.

Main Outcome Measures

Mean visual acuity change from baseline, mean central lesion thickness change from baseline, fluorescein angiography findings, and surgical complications.

Results

Total subfoveal blood displacement was achieved in all 13 eyes (100%). Central lesion thickness decreased from a mean baseline value of 867 μm to a mean value of 379 μm at 1 month after surgery. There was visual improvement in 11 eyes, no visual improvement in 1 eye, and poorer vision in 1 eye. The mean change in Early Treatment Diabetic Retinopathy Study letter score from baseline was 19.4 letters at 1 month (P = 0.006) and 23.3 letters at 3 months (P = 0.001). There was intraoperative macular hole formation.

Conclusions

Submacular air injection with a microneedle facilitates displacement of clots dissolved with tissue plasminogen activator with few complications and results in earlier visual improvement.

Section snippets

Methods

The study was performed in a prospective manner at the Department of Ophthalmology of Yokohama City University Medical Center between January 2013 and October 2013. Institutional review board approval was obtained for this study. Each patient signed an informed consent form. The inclusion criteria were thick SMHs involving the foveal center resulting from age-related macular degeneration and extending into at least 2 quadrants, and a maximum history of symptom duration of 4 weeks. The exclusion

Results

There were 13 subjects (2 women and 11 men), and their mean age was 71 years (range, 62–87 years). The average interval between the onset of symptoms and surgery was 19 days (range, 7–40 days). Preoperative visual acuity in the affected eyes ranged from 20/100 to counting fingers. Total subfoveal blood displacement was achieved in all 13 eyes (100%; Figure 2, Figure 3, Figure 4).

All patients were followed up for a minimum of 3 months. Preoperative and postoperative visual acuity values were

Discussion

Total subfoveal displacement of the dissolved clots and satisfactory visual improvement were achieved in all 13 eyes in this study by submacular injection of tPA and air followed by maintaining a prone position overnight.

Pneumatic displacement is achieved by a simple fluid–air exchange and postoperative positioning.6, 7, 8 Because pneumatic displacement works by decreasing the buoyancy of the SMHs without increasing the buoyancy of the air, SMHs readily drift away from the macular area because

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Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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