Subretinal hemorrhage management by pars plana vitrectomy and internal drainage

Submacular hemorrhage removal

PURPOSE

To determine whether pars plana vitrectomy combined with tissue plasminogen activator for evacuation of submacular hemorrhage results in improved visual acuity.

METHODS

Retrospective review of 18 patients who received a subretinal injection of tissue plasminogen activator during a pars plana vitrectomy to evacuate dense submacular hemorrhages.

RESULTS

Diagnoses included age-related macular degeneration (16 patients), ruptured macroaneurysm (1 patient), and penetrating ocular trauma (1 patient). Preoperative visual acuity ranged from 20/200 to counting fingers (median visual acuity, counting fingers). Follow-up ranged from 10 to 104 weeks (median, 33 weeks). Best postoperative visual acuity ranged from 20/30 to counting fingers (median, 20/300). Best postoperative visual acuity improved two or more lines in 11 (61%) of 18 eyes, remained unchanged in 4 (22%) of 18 eyes, and decreased two or more lines in 3 (17%) of 18 eyes (P = 0.10, Wilcoxon sign-rank test). Final visual acuity ranged from 20/40 to light perception (median, counting fingers). Final visual acuity improved two or more lines in 5 (28%) of 18 eyes, remained unchanged in 6 (33%) of 18 eyes, and decreased two or more lines in 7 (39%) of 18 eyes (P = 0.53, Wilcoxon sign-rank test).

CONCLUSIONS

Pars plana vitrectomy to evacuate massive subretinal hemorrhage can improve visual acuity, but final visual acuity is limited by the underlying disease.

Intraoperative fibrinolysis of submacular hemorrhage with tissue plasminogen activator and surgical drainage

PURPOSE

This pilot study determined the safety and efficacy of intraoperative pharmacologic lysis of recent submacular hemorrhage with tissue plasminogen activator followed by surgical drainage of the unclotted blood in patients with age-related macular degeneration.

METHODS

In a prospective study, 24 consecutive eyes with recent (< 14 days old) submacular hemorrhage secondary to age-related macular degeneration and good visual acuity before development of submacular hemorrhage were treated with vitrectomy, subretinal injection of tissue plasminogen activator, and removal of the liquefied blood. Patients were followed up for at least six months (mean, 14 months).

RESULTS

Twenty eyes (83%) had improved visual acuity after surgery, and eight eyes (33%) attained visual acuity of 20/200 or better. In a subset of 16 eyes with submacular hemorrhage of seven days duration or less, eight (50%) attained visual acuity of 20/200 or better. Factors associated with poor visual outcome included submacular hemorrhage with duration greater than seven days (P < .001), the presence of hemorrhagic pigment epithelial detachment (P = .04), and massive subretinal hemorrhage (P = .04).

CONCLUSIONS

Tissue plasminogen activator thrombolysis may be a valuable adjunct to the surgical treatment of select patients with submacular hemorrhages secondary to age-related macular degeneration.

Treatment of massive subretinal hemorrhage from complications of scleral buckling procedures

Vitrectomy techniques permit removal of subretinal hemorrhage, but the prognosis varies and depends principally on the cause of the hemorrhage. Nine consecutive patients undergoing pars plana vitrectomy with internal drainage of massive subretinal hemorrhage from complications of scleral buckling procedures were studied, to evaluate the long-term results. In all eyes, the final visual acuity was improved, compared with preoperative visual acuity, and was 20/80 or better in seven of nine cases. Recurrent retinal detachment secondary to proliferative vitreoretinopathy developed in two patients, but complete retinal reattachment was achieved after further procedures were performed. Patients with massive subretinal hemorrhage from complications of scleral buckling procedures comprise a subgroup of patients with subretinal hemorrhage in which internal drainage via pars plana vitrectomy is an acceptable alternative to observation only and may result in improved visual acuity outcomes.

Echographic findings in hemorrhagic disciform lesions

PURPOSE

To examine the potential role of ocular echography in the evaluation of hemorrhagic disciform disease.

METHODS

Using standardized ocular echography, the authors examined 85 eyes of 85 patients with hemorrhagic disciform lesions.

RESULTS

Hemorrhagic disciform lesions are located in the subretinal pigment epithelial space and appear echographically as solid chorioretinal elevations characterized by a bumpy, lobulated surface with indistinct peripheral margins, irregular internal structure, and medium to high internal reflectivity. These lesions could be reliably differentiated from associated subretinal or suprachoroidal hemorrhage by ocular echography when the maximal height of the lesion was 1 mm or greater.

CONCLUSIONS

Hemorrhagic disciform disease is usually complex with distinct components that may not be discernible on biomicroscopic or angiographic examination, in part because of overlying subretinal hemorrhage. Ocular echography provides a readily available clinical tool to define the components of hemorrhagic disciform disease more precisely. Improved characterization of hemorrhagic disciform lesions may improve understanding of the natural history and response to therapy of hemorrhagic age-related macular degeneration.

Fibrinolytic-assisted removal of experimental subretinal hemorrhage within seven days reduces outer retinal degeneration

PURPOSE

To better determine the surgical window for removing experimental subretinal hemorrhages in the cat model and to compare the histopathologic effect of such removal with the natural history of untreated subretinal hemorrhages.

METHODS

Twenty-three large experimental subretinal hemorrhages were created with a neodymium:YAG laser focused through a performed retinal bleb in a cohort of cats. Fourteen subretinal hemorrhages were observed without treatment, six were removed at 7 days through a micropipette after injecting 10 micrograms/ml of human recombinant tissue plasminogen activator (rt-PA) into the subretinal space, and three were removed through an access retinotomy without the use of rt-PA. The tissues from these eyes were examined with light and electron microscopy 14 to 28 days after creation of the subretinal hemorrhages.

RESULTS

Severe outer retinal degeneration was evident by day 14 in all of the untreated subretinal hemorrhages 3 disc diameters or greater in size. In contrast, the outer retinal architecture was better preserved in the eyes that underwent rt-PA-assisted removal of their subretinal hemorrhage that was 3 disc diameters or greater on day 7. In these eyes, mild abnormalities such as abnormally short and misaligned photoreceptor outer segments with vacuolization were present within the retina that was formerly located over the hemorrhage center. The eyes that underwent subretinal hemorrhage removal through an access retinotomy without rt-PA on day 7 had a low-lying retinal detachment and outer retinal degeneration.

CONCLUSION

Removing experimental subretinal hemorrhages within 7 days of their occurrence with the assistance of rt-PA and an ultramicrosurgical approach may reduce outer retinal degeneration in the cat model.

Tissue plasminogen activator in the surgical management of subretinal haemorrhage

We report three cases of the use of tissue plasminogen activator (TPA) to aid the surgical removal of subretinal haemorrhage. All patients had choroidal neovascular membranes secondary to age-related macular degeneration. The technique involved infusing a sterile solution of TPA through a small retinotomy and irrigating out the dissolved clot. The visual acuity improved in the first patient from a preoperative 6/36 to 6/18 five weeks after surgery, but subsequently deteriorated to 6/60 after six months from a new choroidal neovascular membrane (CNVM), remaining 6/60 at nine months after surgery. The second patient's visual acuity improved from count fingers to 6/24 three weeks after surgery, but subsequently deteriorated to 6/60 after four months from a new CNVM, remaining 6/60 at nine months after surgery. The third patient's visual acuity improved from count fingers to 6/36 and remains stable at 6/36, eight months after surgery. Although long-term prognosis remains guarded, these early results suggest that TPA may have a role in the management of subretinal haemorrhage.

Evacuation of subretinal hemorrhage

Submacular hemorrhage may cause secondary retinal degeneration. Evacuation of a traumatic submacular hemorrhage in a young man (Case II) was carried out successfully using transbulbar endodiathermy. Final visual acuity was 20/20. A 74-year-old man (Case IV) suffered a big subretinal hemorrhage in his remaining good eye. That same day strong Argon laser coagulations were applied to the retina over the dark, brown hemorrhage with perforation of the retina and visible escape of blood into the vitreous. Four weeks after the treatment the subretinal hemorrhage showed patchy absorption and the visual acuity was 20/60. The visual acuity remained 20/60 and J3, 27 months after the treatment, and useful vision continued for another 15 months.

Ultrastructural immunocytochemistry of subretinal neovascular membranes in age-related macular degeneration

BACKGROUND

The authors studied various cellular and extracellular matrix components of subretinal neovascular membranes (SRNVM) from patients with age-related macular degeneration (ARMD).

METHODS

Electron microscopic immunocytochemistry was used on the subfoveal neovascular membranes surgically removed from three patients with disciform lesions due to ARMD.

FINDINGS

The SRNVMs always contained large "feeder" vessels along with many new capillaries in different stages of maturation. Capillaries were sparse and embedded in an abundant stroma. The majority of the nonvascular cells were either retinal pigment epithelial (RPE) cells or fibroblast-like cells. The RPE cells formed single or multiple layers on one side of the membranes. The stroma was composed mainly of collagen types I and IV and fibronectin, with small amounts of collagen types III, V, and VI. The absence of Bruch's membrane suggests that a splitting may occur between the RPE cells and Bruch's membrane with the new vessels growing into this cleft. A thickened layer of collagen type IV was often present under the RPE cells. The basement membranes of the newly formed capillaries were morphologically ill-defined, and contained substantial amounts of collagen type IV and fibronectin, but, unlike the basement membranes of normal capillaries, they lacked laminin or heparan sulfate proteoglycan.

CONCLUSION

These results on the ultrastructural components of the SRNVMs may be useful in clarifying the nature of the disciform process in ARMD.

Tissue plasminogen activator thrombolysis during surgical evacuation of experimental subretinal hemorrhage

To assess the role for intraoperative thrombolysis during surgical evacuation of massive subretinal hemorrhage, the authors studied the ability of tissue plasminogen activator (tPA) to facilitate removal of an experimental subretinal blood clot through a small drainage retinotomy. In rabbit eyes, a single subretinal injection of tissue plasminogen activator in concentrations of up to 250 micrograms/ml failed to produce significant (greater than 50%) clot dissolution during a 3-hour period. However, repetitive subretinal lavage and aspiration with tPA (50 micrograms/ml) resulted in progressive intraoperative clot dissolution in rabbits and allowed complete evacuation of blood through a small drainage retinotomy in 6 (100%) of 6 cat eyes. Repetitive vigorous subretinal irrigation with saline solution had no discernible effect on clot size in rabbit eyes. Histopathologic examination of cat eyes following tPA-assisted surgical evacuation of subretinal blood showed preservation of the outer retina in 2 eyes and severe atrophy of the outer retina in 4 eyes.

Surgical Excision of Subfoveal Neovascular Membranes in Age-related Macular Degeneration

We studied the results of surgical excision of ten consecutive subfoveal choroidal neovascular membranes in ten patients with age-related macular degeneration. The criteria for surgical eligibility included the following: (1) a clearly identifiable subfoveal membrane occupying the entire foveal avascular zone, (2) a visual acuity of 20/200 or worse, (3) minimal subretinal hemorrhage, and (4) an associated exudative macular detachment. Six of the ten patients showed visual improvement at one-month and three-month follow-up visits and seven showed visual improvement by the six-month examination. All ten maculae remained attached without recurrence of subfoveal neovascular membranes throughout the follow-up period. These results suggested that surgical excision is a viable alternative to laser photocoagulation in patients with subfoveal neovascularization in age-related macular degeneration.

Ultramicrosurgical removal of subretinal hemorrhage in cats

Subretinal hemorrhages are associated with progressive degeneration of the outer retina and a corresponding poor visual prognosis. Mixed results have been reported in previous attempts to remove such subretinal hemorrhages. We developed an ultramicrosurgical system that used the control of a stereotactic micromanipulator to direct a micropipette tip through a small retinotomy into the subretinal space in three cat eyes. Low-dose recombinant tissue plasminogen activator was then introduced into the subretinal space around the subretinal hemorrhage via a controlled microinfusion system. The recombinant tissue plasminogen activator solution facilitated clot lysis and subsequent removal through the micropipette. Light- and electron-microscopic analysis of histopathologic specimens disclosed good preservation of retinal architecture in the three cat eyes in which experimental subretinal hemorrhages were removed. This was in contrast to the retinal degeneration observed in similar but untreated experimental subretinal hemorrhages.

Pathologic features of surgically excised subretinal neovascular membranes in age-related macular degeneration

The histopathologic features of ten consecutive surgically excised subfoveal neovascular membranes from patients with age-related macular degeneration were examined. Ultrastructural features included the following in decreasing order of frequency: endothelium-lined vascular channels, new collagen, fibrocytes, retinal pigment epithelium, erythrocytes, and myofibroblasts. Chronic inflammatory cells were frequently evident and included macrophages, lymphocytes, and plasma cells. Basal laminar deposit or diffuse drusen were observed in six of the membranes. Photoreceptors and Bruch's membrane were each observed in three of the specimens, but were not associated with decreased postoperative visual acuity. Fibrin was observed in eight membranes, either within the stroma of the membrane or in association with subretinal hemorrhage.

Perforating ocular injuries caused by anesthesia personnel

Between February 1988 and May 1990, the authors treated 12 perforating ocular injuries caused by anesthetic injections around the eye. All 12 injections were performed by nonophthalmologists. Eleven were performed by anesthesiologists and one by a certified nurse anesthetist. Five were caused by blunt needles and seven by sharp needles. Two of the eyes had multiple posterior exit wounds. The five eyes that had sharp needle, single perforations (i.e., one entrance wound and one exit wound) were easily managed with cryopexy, laser, or observation. All five of these eyes have a visual acuity of 20/40 or better. Six vitrectomies were performed on the five patients with single perforations caused by blunt needles; three of these eyes have a visual acuity of counting fingers or worse. The two patients who had multiple posterior exit wounds required a total of four procedures. The visual acuity in these eyes is 20/400 and light perception. Anesthesia personnel should be well trained before attempting ocular anesthesia. The use of blunt needles does not prevent ocular penetration.

Surgical removal of subfoveal neovascularization in the presumed ocular histoplasmosis syndrome

We treated two patients with presumed ocular histoplasmosis, subfoveal neovascular membranes, and progressive visual acuity loss to 20/400. Vitreoretinal surgical techniques were used to remove the subfoveal membranes. Visual acuity returned to 20/20 with seven months of follow-up in one patient (Case 1) and to 20/40 with three months of follow-up in the other patient (Case 2). No evidence of persistent or current subretinal neovascular membranes in either patient have been noted. These preliminary results suggest that vitreoretinal surgical techniques may be successful in mechanically removing subfoveal neovascular membranes with preservation of overlying neurosensory retina and thus preservation of central visual acuity.

Surgical removal of massive subretinal hemorrhage associated with age-related macular degeneration

The authors report on 11 patients with age-related macular degeneration associated with massive subretinal hemorrhage, who were treated with surgical removal of the hemorrhage and associated fibrosis. Preoperative visual acuity ranged from 20/400 to hand motions. Postoperative visual acuity ranged from 20/200 to light perception with a minimum of 3 months of follow-up. Complications included partial or total retinal detachment in four patients (36%) and cataract in four patients (36%). Four of 11 patients showed some improvement in vision (36%). All four of these patients had surgery within 1 week of the onset of severe visual loss. Although surgical removal of large subretinal hemorrhages is technically feasible, visual recovery is limited, even in uncomplicated cases, by macular degenerative changes.