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Barayev E, Tiosano A, Zlatkin R, Elul R, Dotan A, Hadayer A, Gal-Or O, Ehrlich R. Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration. Eur J Ophthalmol 2024; 34:825-833. [PMID: 37715632 DOI: 10.1177/11206721231202048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
PURPOSE To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration. METHODS This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200. RESULTS Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement. CONCLUSION Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.
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Affiliation(s)
- Edward Barayev
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Tiosano
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rita Zlatkin
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem Elul
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Adelson Faculty of Medicine, Ariel University, Ariel, Israel
| | - Assaf Dotan
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Hadayer
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Gal-Or
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rita Ehrlich
- Department of Ophthalmology, Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Szeto SKH, Tsang CW, Mohamed S, Lee GKY, Lok JKH, Hui VWK, Tsang KK, Chen LJ, Brelen M, Lai TYY. Displacement of Submacular Hemorrhage Using Subretinal Cocktail Injection versus Pneumatic Displacement: A Real-World Comparative Study. Ophthalmologica 2024; 247:118-132. [PMID: 38408445 PMCID: PMC11160427 DOI: 10.1159/000537953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/16/2024] [Indexed: 02/28/2024]
Abstract
INTRODUCTION The objective of this study was to compare the outcome of submacular hemorrhage (SMH) displacement using pneumatic displacement with intravitreal expansile gas versus pars plana vitrectomy (PPV) with subretinal injection of tissue plasminogen activator (tPA), anti-vascular endothelial growth factor (VEGF) agent, and air as primary surgery. METHODS Retrospective interventional case series of 63 patients who underwent surgical displacement of SMH secondary to neovascular age-related macular degeneration (nAMD) or polypoidal choroidal vasculopathy (PCV) from May 1, 2015, to October 31, 2022. Medical records were reviewed for diagnosis, logMAR visual acuity (VA), central subfield thickness (CST), and postoperative displacement rates and complications up to 12 months after operation. RESULTS The diagnosis was nAMD in 24 (38.1%) and PCV in 39 (61.9%) eyes. There were 40 (63.5%) eyes in the pneumatic displacement group (38 received C3F8, 2 received SF6) and 23 (36.5%) eyes in the subretinal cocktail injection. Mean baseline VA was 1.46 and 1.62, respectively (p = 0.404). The subretinal injection group had more extensive SMH (p = 0.005), thicker CST (1,006.6 μm vs. 780.2 μm, p = 0.012), and longer interval between symptom and operation (10.65 vs. 5.53 days, p < 0.001). The mean postoperative VA at 6 months was 0.67 and 0.91 (p = 0.180) for pneumatic displacement and subretinal injection groups, respectively, though VA was significantly better in the pneumatic group at 12-month visit (0.64 vs. 1.03, p = 0.040). At least 10 mean change in VA were >10 letters gain in both groups up to 12 months. Postoperative CST reduction was greater (625.1 μm vs. 326.5 μm, p = 0.008) and complete foveal displacement (87.0% vs. 37.5%), p < 0.001, odds ratio [OR] = 11.1) and displacement to arcade or beyond (52.5% vs. 17.5%, p = 0.009, OR = 5.15) were more frequent in the subretinal injection group. Two patients with failed pneumatic displacement were successfully treated with subretinal cocktail injection as a second operation. CONCLUSION Surgical displacement of SMH leads to clinically meaningful improvement in VA. PPV with subretinal cocktail injection is more effective than pneumatic displacement in displacing SMH with similar safety profile despite longer interval before operation, higher CST, and more extensive SMH at baseline. Retinal surgeons could consider this novel technique in cases with thick and extensive SMH or as a rescue secondary operation in selected cases.
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Affiliation(s)
- Simon K H Szeto
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China,
- Hong Kong Eye Hospital, Hong Kong, Hong Kong, China,
- Pao So Kok Macular Disease Treatment and Research Centre, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China,
| | - Chi Wai Tsang
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, Hong Kong, China
| | - Shaheeda Mohamed
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, Hong Kong, China
| | - Gary K Y Lee
- The Hong Kong Ophthalmic Associates, Hong Kong, Hong Kong, China
| | - Jerry K H Lok
- Hong Kong Ophthalmic Specialists, Hong Kong, Hong Kong, China
| | - Vivian W K Hui
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, Hong Kong, China
| | - Ken K Tsang
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, Hong Kong, China
| | - Li Jia Chen
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Department of Ophthalmology, Prince of Wales Hospital, Hong Kong, Hong Kong, China
| | - Marten Brelen
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Pao So Kok Macular Disease Treatment and Research Centre, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
- Department of Ophthalmology, Prince of Wales Hospital, Hong Kong, Hong Kong, China
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong, China
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Begaj T, Jeong D, Park JG, Runner MM, Capone A, Dass AB, Drenser KA, Faia LJ, Farley ND, Garretson BR, Hassan TS, Mahmoud TH, Margherio A, Raphaelian PV, Randhawa S, Ruby AJ, Sneed S, Rao P, Wolfe JD, Williams GA. LONG-TERM USE OF ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2024; 44:222-229. [PMID: 37903288 DOI: 10.1097/iae.0000000000003961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
PURPOSE Although pivotal trials have demonstrated efficacy of anti-vascular endothelial growth factor therapy in neovascular age-related macular degeneration, there is a paucity of clinical data about the long-term (>5 years) treatment. METHODS Retrospective analysis of all patients with neovascular age-related macular degeneration who were actively treated, had received >40 anti-vascular endothelial growth factor injections, and were followed for ≥5 years. Snellen-corrected visual acuity, initial drug choice, and times elapsed between treatments were collected. Rates of endophthalmitis and outcomes of submacular hemorrhage were also evaluated. RESULTS A total of 88 patients (162 eyes) met the inclusion criteria: the average patient age was 86.3 years with an average follow-up period of 7.6 years. The average total number of injections per eye was 69 (18.0 SD); a total of 11,208 injections were given throughout the study period, and 6 cases (0.05%) of endophthalmitis were observed. Overall, there was a clinical and statistical difference in average Snellen-corrected visual acuity at Injections #2,#3, #4, #5, #6, #10, and #20, as compared with baseline ( P = 0.03, P < 0.01, P = 0.02, P < 0.01, P = 0.01, P = 0.01, P < 0.01, respectively). Patients in the Snellen-corrected visual acuity subgroup 20/20 to 20/40 maintained vision until injection #30. Seven eyes experienced a visually significant submacular hemorrhage. CONCLUSION This neovascular age-related macular degeneration cohort received on average eight anti-vascular endothelial growth factor injections per year for approximately 8 years; eyes with good (≥20/40) initial baseline vision maintained their visual acuity, whereas those with worse Snellen-corrected visual acuity (≤20/50) had a robust initial improvement that diminished with time. Most patients were maintained on the same initial drug of choice and the rate of endophthalmitis was low.
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Affiliation(s)
- Tedi Begaj
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Daeun Jeong
- Oakland University William Beaumont, Rochester, Michigan
| | - Jong G Park
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Margaret M Runner
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Antonio Capone
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - A Bawa Dass
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Kimberly A Drenser
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Lisa J Faia
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Nathan D Farley
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
| | - Bruce R Garretson
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Tarek S Hassan
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Tamer H Mahmoud
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Alan Margherio
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
| | | | - Sandeep Randhawa
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Alan J Ruby
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Scott Sneed
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - Prethy Rao
- Retina and Vitreous of Texas, Houston, Texas
| | - Jeremy D Wolfe
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
| | - George A Williams
- Associated Retinal Consultants/Beaumont Health, Royal Oak, Michigan
- Oakland University William Beaumont, Rochester, Michigan
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Iglicki M, Khoury M, Donato L, Quispe DJ, Negri HP, Melamud JI. Comparison of subretinal aflibercept vs ranibizumab vs bevacizumab in the context of PPV, pneumatic displacement with subretinal air and subretinal tPA in naïve submacular haemorrhage secondary to nAMD. "The Submarine Study". Eye (Lond) 2024; 38:292-296. [PMID: 37537388 PMCID: PMC10810790 DOI: 10.1038/s41433-023-02676-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 08/05/2023] Open
Abstract
OBJECTIVE To compare efficacy and safety profile of subretinal aflibercept, ranibizumab, and bevacizumab in the context of pars plana vitrectomy, pneumatic displacement with subretinal air and subretinal tPA for subretinal macular haemorrhage (SMH) due to naïve neovascular age-related macular degeneration (nAMD). DESIGN Retrospective interventional cohort study. PARTICIPANTS 123 eyes of 123 patients treated with subretinal aflibercept (n = 41, 33%), ranibizumab (n = 41,33%), and bevacizumab (n = 41, 33%). METHODS Review of electronic medical records for best corrected visual acuity (BCVA), central subfoveal thickness (CST), and intraocular pressure (IOP) at baseline and 24 months after treatment. MAIN OUTCOME MEASURES BCVA, CST, and number of intravitreal anti VEGF over 24 months. RESULTS Mean age of patients was 80.5 ± 5.5 years, 43.9% were female. Mean time from symptom onset until surgery was 1.1 days (range 0-3 days). In all cases, the SMH did not reach the arcades. CST at baseline was 627 ± 140 µ, 739 ± 54 µ, and 793 ± 93 µ (p = 0.0001) for aflibercept, ranibizumab, or bevacizumab, respectively. Baseline BCVA (logMAR) was 0.65 ± 0.13, 0.69 ± 0.96, and 0.74 ± 0.81 (p = 0.0041) for aflibercept, ranibizumab, and bevacizumab, respectively. All three groups showed statistically significant improvement in BCVA and CST (for all groups: p < 0.001). There was no statistically significant difference at the final BCVA (p = 0.789). The mean number of anti VEGF given during follow-up period was 5.2 ± 0.81, 4.4 ± 0.63, and 5.5 ± 0.95 (p = 0.0001) for aflibercept, ranibizumab, and bevacizumab, respectively. CONCLUSION This study shows that aflibercept, ranibizumab, and bevacizumab in a subretinal manner in the context of PPV, pneumatic displacement with subretinal air and subretinal tPA for subretinal macular haemorrhage secondary to naïve nAMD work with the same efficacy and safety profile.
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Affiliation(s)
- Matias Iglicki
- Private Retina Office, University of Buenos Aires, Buenos Aires, Argentina.
| | - Marina Khoury
- Medical Investigation Institute "Alfredo Lanari", University of Buenos Aires, Buenos Aires, Argentina
| | - Lucas Donato
- Ophthalmologic Institute, Buenos Aires, Argentina
| | | | | | - Javier Ignacio Melamud
- Medical Investigation Institute "Alfredo Lanari", University of Buenos Aires, Buenos Aires, Argentina
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Confalonieri F, Ferraro V, Barone G, Di Maria A, Petrovski BÉ, Vallejo Garcia JL, Randazzo A, Vinciguerra P, Lumi X, Petrovski G. Outcomes in the Treatment of Subretinal Macular Hemorrhage Secondary to Age-Related Macular Degeneration: A Systematic Review. J Clin Med 2024; 13:367. [PMID: 38256501 PMCID: PMC10816885 DOI: 10.3390/jcm13020367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Background: Subretinal macular hemorrhage (SRMH) secondary to age-related macular degeneration (AMD) is a relatively rare condition in ophthalmology characterized by blood collection between the neurosensory retina and the retinal pigment epithelium (RPE). Without prompt treatment, visual prognosis is poor. A plethora of treatment approaches have been tried over the past years ranging from intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy to direct subretinal surgery, with no conclusive superiority of one over the other. Materials and Methods: We conducted a systematic review of the outcomes and treatment modalities of SRMH from inception to 14 June 2022, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). The level of evidence was assessed for all included articles according to the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: A total of 2745 articles were initially extracted, out of which 1654 articles were obtained after duplicates were removed and their abstracts screened. A total of 155 articles were included for full-text review. Finally, 81 articles remained that fulfilled the inclusion criteria. Conclusions: Even though there are solid results supporting a variety of treatments for SRMH, the best treatment modality has still not been conclusively demonstrated and further research is needed.
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Affiliation(s)
- Filippo Confalonieri
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (B.É.P.); (X.L.)
- Department of Ophthalmology, Oslo University Hospital, Kirkeveien 166, 0450 Oslo, Norway
| | - Vanessa Ferraro
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Gianmaria Barone
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandra Di Maria
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Beáta Éva Petrovski
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (B.É.P.); (X.L.)
| | - Josè Luis Vallejo Garcia
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Alessandro Randazzo
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Paolo Vinciguerra
- Department of Ophthalmology, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (V.F.); (G.B.); (A.D.M.); (J.L.V.G.); (P.V.)
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Xhevat Lumi
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (B.É.P.); (X.L.)
- Eye Hospital, University Medical Centre Ljubljana, Zaloška Cesta 2, 1000 Ljubljana, Slovenia
| | - Goran Petrovski
- Center for Eye Research and Innovative Diagnostics, Department of Ophthalmology, Institute for Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway; (B.É.P.); (X.L.)
- Department of Ophthalmology, Oslo University Hospital, Kirkeveien 166, 0450 Oslo, Norway
- Department of Ophthalmology, University of Split School of Medicine and University Hospital Centre, 21000 Split, Croatia
- UKLONetwork, University St. Kliment Ohridski-Bitola, 7000 Bitola, North Macedonia
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Zheng F, Xu Z, He J, Liu Y, Xu Y, Ma J, Fang X. Rapid flattening of massive hemorrhagic retinal pigment epithelial detachment secondary to polypoidal choroidal vasculopathy after surgery. Am J Ophthalmol Case Rep 2023; 32:101907. [PMID: 37560557 PMCID: PMC10407114 DOI: 10.1016/j.ajoc.2023.101907] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/03/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023] Open
Abstract
PURPOSE To report 2 polypoidal choroidal vasculopathy (PCV) patients whose massive hemorrhagic pigment epithelial detachments (PEDs) were flattened within a short period after surgery. OBSERVATIONS Two PCV patients who presented with submacular hemorrhage and massive hemorrhagic PEDs with sizes of more than 50 disc areas underwent pars plana vitrectomy combined with subretinal injection of tissue plasminogen activator (tPA), intravitreous injection of anti-vascular endothelial growth factor medicine, and perfluoropropane tamponade. The massive hemorrhagic PEDs were flattened within a short period after both surgeries, and both patients experienced improved visual acuity. CONCLUSIONS These findings suggest that subretinal injection of tPA together with perfluoropropane tamponade promotes the rapid clearance of hemorrhage under RPE.
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Affiliation(s)
- Fang Zheng
- Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Zhangxing Xu
- Ophthalmology Department, Ningbo Medical Centre Lihuili Hospital, Ningbo, China
| | - Jingliang He
- Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Ye Liu
- Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Yufeng Xu
- Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Ma
- Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoyun Fang
- Eye Center, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang University, Hangzhou, China
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Abdulaal M, Donkor R, Robertson J, Lewis S, Miller DG, Schartman J, Platt S, Coney JM. Early surgical displacement of submacular hemorrhage without tissue plasminogen activator use: one-year outcomes. CANADIAN JOURNAL OF OPHTHALMOLOGY 2023:S0008-4182(23)00310-1. [PMID: 37925165 DOI: 10.1016/j.jcjo.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/15/2023] [Accepted: 10/04/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE This study evaluated changes in best-corrected visual acuity and submacular hemorrhage (SMH) resolution in eyes after a single rapid subretinal displacement surgery using subretinal balanced saline solution and sterile air without tissue plasminogen activator (tPA). DESIGN A retrospective comparative interventional analysis. PARTICIPANTS Twenty-six eyes with thick SMH who underwent pars plana vitrectomy and subretinal fluid displacement without tPA from 2015 and 2021 and at least 1-year of follow-up. METHODS Surgical intervention included a standard small-gauge pars plana vitrectomy with subretinal displacement using balanced saline solution with subretinal sterile air and partial gas-air fluid exchange. Main outcome measures included degree of subfoveal SMH displacement, best and final postoperative visual acuities, and adverse events. Snellen acuity was converted to logMARs for statistical analysis. RESULTS The most common etiology associated with thick SMH (92.3%) was neovascular age-related macular degeneration. Within 1 month postoperatively, 21 patients (80.8%) saw complete subfoveal blood displacement. Most of the SMH surgical displacements were done within 1 week of presenting symptoms. Average preoperative duration of SMH was 3.60 ± 2.78 days (range, 1-12 days). Mean logMAR best-corrected visual acuity improved from 1.63 ± 0.58 (Snellen 20/800 baseline) to 0.90 ± 0.42 letters (Snellen 20/160) at last follow-up (p = 0.001). This study's visual acuity improvement is comparable with that of prior studies using tPA. Early postoperative complications included 1 retinal detachment, 1 vitreous hemorrhage, and 1 macular hole. CONCLUSION Rapid surgery with subretinal balanced saline solution-sterile air injection without tPA was found to be effective for displacement of thick SMH with retinal function, visual acuity, and corneal refractive therapy improvement.
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Affiliation(s)
| | | | | | - Shawn Lewis
- Retina Associates of Cleveland, Beachwood, OH
| | | | | | - Sean Platt
- Retina Associates of Cleveland, Beachwood, OH
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Miki M, Miyata M, Ooto S, Tamura H, Ueda-Arakawa N, Muraoka Y, Miyake M, Hata M, Takahashi A, Kido A, Kogo T, Uji A, Tsujikawa A. PREDICTORS OF 3-MONTH AND 1-YEAR VISUAL OUTCOMES AFTER VITRECTOMY WITH SUBRETINAL TISSUE PLASMINOGEN ACTIVATOR INJECTION FOR SUBMACULAR HEMORRHAGE. Retina 2023; 43:1971-1979. [PMID: 37490778 DOI: 10.1097/iae.0000000000003885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
PURPOSE To investigate factors associated with 3-month or 1-year best-corrected visual acuity (BCVA) after vitrectomy with subretinal tissue plasminogen activator injection for submacular hemorrhage (SMH) and to identify the predictors of early displacement. METHODS This prospective cohort study included consecutive eyes with SMH complicating neovascular age-related macular degeneration or retinal macroaneurysm that underwent vitrectomy with subretinal tissue plasminogen activator injection and were followed up for at least 3 months. Parameters that correlated with 3-month BCVA, 1-year BCVA, and 2-week displacement grade (0-3) were identified. RESULTS Twenty-nine eyes of 29 patients (73.1 ± 8.4 years; neovascular age-related macular degeneration, 25 eyes) were included. Logarithm of the minimum angle of resolution BCVA improved 3 months after the surgery (baseline, 0.76 [20/115] ± 0.35; 3-month, 0.51 [20/65] ± 0.32; P = 0.006). In multivariable analyses, 1-year logarithm of the minimum angle of resolution BCVA correlated with age ( P = 0.007, β = 0.39) and SMH recurrence within 1 year after surgery ( P < 0.001, β = 0.65). Two-week displacement grade correlated with the contrast-to-noise ratio of SMH ( P = 0.001, β = -0.54). Macular hole occurred in three eyes (10%) with small SMH size and was closed in all eyes via additional vitrectomy with an inverted internal limiting membrane flap technique. CONCLUSION The recurrence of SMH negatively affected the 1-year visual outcome after vitrectomy with subretinal tissue plasminogen activator injection for SMH. The contrast-to-noise ratio was a useful predictor of early SMH displacement, but not of 1-year BCVA. Further research is necessary to determine the optimal treatment to prevent SMH recurrence.
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Affiliation(s)
- Makoto Miki
- Faculty of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto City, Kyoto Prefecture, Japan; and
| | - Manabu Miyata
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Sotaro Ooto
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Hiroshi Tamura
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Naoko Ueda-Arakawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Yuki Muraoka
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Masahiro Miyake
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Masayuki Hata
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Ayako Takahashi
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Ai Kido
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Takahiro Kogo
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Akihito Uji
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
| | - Akitaka Tsujikawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Sakyo-Ku, Kyoto City, Kyoto Prefecture, Japan
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Iglicki M, Khoury M, Melamud JI, Donato L, Barak A, Quispe DJ, Zur D, Loewenstein A. Naïve subretinal haemorrhage due to neovascular age-related macular degeneration. pneumatic displacement, subretinal air, and tissue plasminogen activator: subretinal vs intravitreal aflibercept-the native study. Eye (Lond) 2023; 37:1659-1664. [PMID: 36038720 PMCID: PMC10220048 DOI: 10.1038/s41433-022-02222-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE We aimed to compare visual and anatomical outcome in subretinal aflibercept vs. intravitreal aflibercept in the context of Pars Plana Vitrectomy (PPV), pneumatic displacement with subretinal air and subretinal tPA in patients with naïve submacular haemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD). DESIGN Retrospective interventional cohort study. PARTICIPANTS 80 patients treated with subretinal aflibercept vs. intravitreal aflibercept in the context of PPV, subretinal air and subretinal tPA in patients with SMH secondary to naïve nAMD. METHODS Records were reviewed. Best corrected visual acuity (BCVA), central subfoveal thickness (CST), and intraocular pressure (IOP) were recorded at baseline and 24 months after treatment. MAIN OUTCOME MEASURES BCVA, CST, and number of anti VEGF treatment over follow-up period. RESULTS The average duration from onset of symptoms to surgery was 1.26 days (range 0-3 days). Based on review of OCT images, SMH was subretinal in all 80 patients (100%), and sub-RPE in 29 patients (36.3%). Forty-one patients (51.25%) were treated with subretinal aflibercept ("subretinal group"), and 39 patients (48.75%) were treated with intravitreal aflibercept injections ("intravitreal group"). The groups were well balanced for age and gender p = 0.6588, and p = 0.263, respectively). Both groups showed statistically significant improvement in BCVA and CST (for all groups: p < 0.001). The mean number of anti VEGF given during follow-up period was statistically significantly lower in the "subretinal group" (p < 0.0001). CONCLUSION This study shows better management of the CNV, with a statistically significant lower need for anti-VEGF injections when treated with subretinal aflibercept compared to intravitreal application.
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Affiliation(s)
- Matias Iglicki
- Private Retina Office, University of Buenos Aires, Buenos Aires, Argentina.
| | - Marina Khoury
- Medical Investigation Institute "Alfredo Lanari", University of Buenos Aires, Buenos Aires, Argentina
| | - Javier Ignacio Melamud
- Medical Investigation Institute "Alfredo Lanari", University of Buenos Aires, Buenos Aires, Argentina
| | - Lucas Donato
- Ophthalmologic Institute, Buenos Aires, Argentina
| | - Adiel Barak
- Division of Ophthalmology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Diego Jose Quispe
- Private Retina Office, University of Buenos Aires, Buenos Aires, Argentina
| | - Dinah Zur
- Division of Ophthalmology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Loewenstein
- Division of Ophthalmology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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10
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Garg SJ, Gekeler F. SUBRETINAL AIR USED AS A BALL VALVE TO STABILIZE A RETINAL BLEB. Retin Cases Brief Rep 2023; 17:189-190. [PMID: 33731602 DOI: 10.1097/icb.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a technique of using subretinal air to create and stabilize a neurosensory detachment performed during placement of a subretinal implant. METHODS A case report of an experiment in a live porcine model. RESULTS Creation of a neurosensory detachment may be facilitated by instillation of subretinal air. We use a small-gauge cannula to infuse approximately 0.1 mL of subretinal air to create a neurosensory detachment. We then expand the bleb using an additional 0.1 cc to 0.2 cc of subretinal air followed by balanced salt solution and stabilize it further with installation of viscoelastic. The small-gauge retinotomy should be created on the anterior and superior aspect of the bleb so that the air can tamponade the retinotomy both during surgery and postoperatively. CONCLUSION This technique may be useful for some newer procedures, such as subretinal implants and perhaps administration of subretinal gene therapy or cell therapy, that require access to the subretinal space.
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Affiliation(s)
- Sunir J Garg
- Mid Atlantic Retina, The Retina Service of Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania; and
| | - Florian Gekeler
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany
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11
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Efficacy Evaluation of Tissue Plasminogen Activator with Anti-Vascular Endothelial Growth Factor Drugs for Submacular Hemorrhage Treatment: A Meta-Analysis. J Clin Med 2023; 12:jcm12031035. [PMID: 36769682 PMCID: PMC9918283 DOI: 10.3390/jcm12031035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Submacular hemorrhage (SMH) is the accumulation of blood in the macular area that can severely damage the macular structure and visual function. Recently, the intraocular administration of tissue plasminogen activator (TPA) with anti-vascular endothelial growth factor (anti-VEGF) drugs was reported to have a positive effect on SMH. This meta-analysis aimed to explore the efficacy and safety of the drug combination. We systematically searched the Web of Science, MEDLINE, EMBASE, and Cochrane Library databases and screened relevant full-length literature reports. The quality of the reports was assessed by two independent reviewers. The best-corrected visual acuity (BCVA) and foveal thickness (FT) were considered the main indicators of efficacy. RevMan 5.4 software was used for this meta-analysis. Twelve studies were analyzed, and the results showed that BCVA at 1 month (p < 0.001), 3 months (p < 0.001), 6 months (p < 0.001), and the last follow-up (p < 0.001) was improved relative to the preoperative value. The postoperative FT was lower than the preoperative FT (p < 0.001). No significant difference in efficacy was observed between subretinal and intravitreal TPA injections (p = 0.37). TPA with anti-VEGF drugs is safe for SMH treatment and can significantly improve BCVA and reduce FT.
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12
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Tiosano A, Gal-Or O, Fradkin M, Elul R, Dotan A, Hadayer A, Brody J, Ehrlich R. Visual acuity outcome in patients with subretinal hemorrhage - office procedure vs. surgical treatment. Eur J Ophthalmol 2023; 33:506-513. [PMID: 35532042 DOI: 10.1177/11206721221098208] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the effects of intravitreal injection of tissue plasminogen activator (tPA) and gas vs. pars plana vitrectomy (PPV) surgery as first-line treatment for subretinal hemorrhage. METHODS Retrospective study of 107 adults treated for subretinal hemorrhage at a tertiary hospital during 2008-2019; 51 received injection of tPA and gas and 56 underwent PPV. RESULTS No between-group differences were found in age and sex, medical history, use of anticoagulants or antiplatelets, history of ocular surgeries, and previous use of intravitreal anti-VEGF. Overall follow-up time was longer in the PPV group (median 4.9 vs 3.28 years, p = 0.005). The hemorrhage was displaced in a similar percentage of patients in the tPA-and-gas group (n = 40, 78.4%) and the PPV group (n = 45, 80.4%) (p = 0.816). Approximately 80% of patients in the tPA-and-gas group were able to forgo PPV surgery. Visual acuity (in LogMAR) was similar in the two groups prior to the diagnosis of subretinal hemorrhage but better in the tPA-and-gas group at the end of follow-up (p < 0.001). CONCLUSION Injection of gas and tPA can be done immediately following diagnosis of subretinal hemorrhage as an office procedure. Visual acuity outcome is good, with a high rate of blood displacement. About 20% of patients might require additional PPV as secondary intervention.
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Affiliation(s)
- Alon Tiosano
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Orly Gal-Or
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Maayan Fradkin
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Rotem Elul
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Adelson Faculty of Medicine, 42732Ariel University, Ariel, Israel
| | - Assaf Dotan
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Amir Hadayer
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Judith Brody
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Rita Ehrlich
- Department of Ophthalmology, 36632Rabin Medical Center - Beilinson Hospital, Petach Tikva, Israel.,Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
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13
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Ogata M, Oh H, Nakata A, Doi A, Nakayama H, Hasegawa M, Hirose M. Displacement of submacular hemorrhage secondary to age-related macular degeneration with subretinal injection of air and tissue plasminogen activator. Sci Rep 2022; 12:22139. [PMID: 36550175 PMCID: PMC9780236 DOI: 10.1038/s41598-022-26289-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Submacular hemorrhage (SMH) can lead to devastating visual loss in patients with age-related macular degeneration. We retrospectively evaluated the surgical outcomes of vitrectomy with subretinal injection of tissue plasminogen activator, bevacizumab, and air in 13 cases. Visual prognosis, anatomical results obtained with optical coherence tomography (OCT), and their correlations were investigated. We analyzed OCT parameters including SMH height, pigment epithelial detachment (PED) height and width, and status of ellipsoid zone (EZ) line. Complete displacement of SMH was achieved in 12 eyes. At 3 months post-surgery, best-corrected visual acuity (BCVA) and SMH height exhibited significant improvements (P < 0.01). In eyes with preoperative SMH height < 300 µm and a detectable EZ line, BCVA was significantly improved at as early as 1 month, whereas the remaining eyes exhibited visual improvements only at 3 months. Postoperative BCVA positively correlated with preoperative BCVA (r = 0.86, P < 0.005), and negatively correlated with SMH size (r = 0.69, P < 0.01) and PED height (r = 0.58, P < 0.05) and width (r = 0.67, P < 0.05). Multivariate analyses confirmed preoperative BCVA as the predominant factor associated with postoperative BCVA (β = 1.093, P < 0.05). In conclusion, significant improvements in BCVA and anatomical findings can be achieved with our reported surgical technique. Preoperative OCT findings may influence the duration required for visual improvements.
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Affiliation(s)
- Maasa Ogata
- grid.413697.e0000 0004 0378 7558Department of Ophthalmology, Hyogo Prefectural Amagasaki General Medical Center, Higashinaniwa-Cho 2-17-77, Amagasaki, Hyogo 660-8550 Japan
| | - Hideyasu Oh
- grid.413697.e0000 0004 0378 7558Department of Ophthalmology, Hyogo Prefectural Amagasaki General Medical Center, Higashinaniwa-Cho 2-17-77, Amagasaki, Hyogo 660-8550 Japan
| | - Ai Nakata
- grid.413697.e0000 0004 0378 7558Department of Ophthalmology, Hyogo Prefectural Amagasaki General Medical Center, Higashinaniwa-Cho 2-17-77, Amagasaki, Hyogo 660-8550 Japan
| | - Ayaka Doi
- grid.415977.90000 0004 0616 1331Department of Ophthalmology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Hiroki Nakayama
- grid.410783.90000 0001 2172 5041Department of Ophthalmology, Kansai Medical Universal Hospital, Osaka, Japan
| | - Mariko Hasegawa
- grid.413697.e0000 0004 0378 7558Department of Ophthalmology, Hyogo Prefectural Amagasaki General Medical Center, Higashinaniwa-Cho 2-17-77, Amagasaki, Hyogo 660-8550 Japan
| | - Miou Hirose
- grid.413697.e0000 0004 0378 7558Department of Ophthalmology, Hyogo Prefectural Amagasaki General Medical Center, Higashinaniwa-Cho 2-17-77, Amagasaki, Hyogo 660-8550 Japan
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14
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Simultaneous intravitreal aflibercept and gas injections for submacular hemorrhage secondary to polypoidal choroidal vasculopathy. Graefes Arch Clin Exp Ophthalmol 2022; 261:1545-1552. [DOI: 10.1007/s00417-022-05922-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 11/01/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
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15
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AlZaid A, Magliyah M, Saifaldein AA, AlBalawi HB, Mura M, Al-Dhibi H. Retinal periphlebitis associated with branch retinal vein occlusion and complicated by subfoveal hemorrhage: a case report. J Int Med Res 2022; 50:3000605221137478. [DOI: 10.1177/03000605221137478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Retinal periphlebitis is a subtype of retinal vasculitis affecting the retinal veins. We report a case of bilateral branch retinal vein occlusion (BRVO) associated with idiopathic retinal periphlebitis and complicated by subfoveal hemorrhage (SFH). An 18-year-old woman presented with best-corrected visual acuity of 20/20 in the right eye and 20/30 in the left eye. Examination revealed bilateral retinal vascular sheathing predominantly involving the retinal veins and bilateral BRVO. Fundus fluorescein angiography revealed localized vascular leakage in the right eye and diffuse vascular leakage in the left eye. Spectral-domain optical coherence tomography showed mild nasal thickening with subfoveal fluid in the left eye. Oral steroids were started on a tapering dosage as well as oral methotrexate. A year later, she presented with regressed vascular sheathing in both eyes with 5/200 vision and SFH in the left eye. Pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal ranibizumab, laser photocoagulation, and gas injection were performed. The SFH resolved and the visual acuity improved to 20/100. Good vision was preserved in both eyes with no active inflammation. Timely management of SFH in idiopathic retinal periphlebitis can achieve a favorable visual outcome.
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Affiliation(s)
- Abdulrahman AlZaid
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Moustafa Magliyah
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
- Department of Ophthalmology, Prince Mohammed Medical City, Aljouf, Saudi Arabia
| | | | - Hani B AlBalawi
- Department of Surgery, Division of Ophthalmology, Faculty of Medicine, Ophthalmology Department, University of Tabuk, Tabuk City, Saudi Arabia
| | - Marco Mura
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Hassan Al-Dhibi
- Vitreoretinal Division, King Khalid Eye Specialist Hospital, Riyadh, Saudi Arabia
- Alfaisal University, College of Medicine, Riyadh, Saudi Arabia
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16
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Pars plana vitrectomy and subretinal tissue plasminogen activator for large exudative submacular hemorrhage: a case series. BMC Ophthalmol 2022; 22:411. [PMID: 36303103 PMCID: PMC9615203 DOI: 10.1186/s12886-022-02639-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate anatomical and functional outcomes of patients with large submacular hemorrhage (SMH) who treated by pars plana vitrectomy (PPV) in combination with subretinal tissue plasminogen activator (TPA) injection, intraocular gas tamponade, and with additional post-operative interventions. METHODS Medical records of 9 patients who presented with large SMH secondary to age-related macular degeneration (AMD) and underwent PPV, subretinal TPA injection, and gas tamponade at Chiang Mai university hospital between January 2012 and January 2020 were reviewed. Collected data included preoperative visual acuity (VA), SMH extent and duration, intraoperation and post-operation complications, post-operative anatomical and VA responses, and the need for administer post-operation additional treatments. RESULTS Overall, five patients were male and four patients were female with a mean (SD) age of 66.9 (7.7) years and a mean (SD) follow-up of 21.1 (16.1) months. A mean (SD) duration of SMH was 15.1 (10.9) days with a mean (SD) extent of SMH was 6.2 (3.4) disc diameters. At 1-month post-operation, complete SMH displacement was noted in eight (88.9%) patients. The mean (SD) VA significantly improved from LogMAR 1.9 (0.4) to 1.1 (0.4), (P = 0.004). During follow-up, eight patients (88.9%) were given additional therapy (anti-vascular endothelial growth factor (anti-VEGF) monotherapy, photodynamic therapy, or in combination). At final follow-up, a mean (SD) LogMAR VA of 0.9 (0.4) was significantly improved compared to baseline (P = 0.004). For intra- and post-operation complications, none developed intraoperative retinal break and retinal detachment. CONCLUSIONS Vitrectomy with subretinal TPA injection, intraocular gas tamponade, and additional post-operation treatments provide benefit for anatomical and visual outcomes for patients with large SMH. It may consider as one of effective treatment in this group of patients.
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Mohammed TK, Simon CL, Gorman EF, Taubenslag KJ. Management of Submacular Hemorrhage. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00330-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Mun Y, Park KH, Park SJ, Cho HJ, Kim CG, Kim JW, Park DG, Sagong M, Kim JH, Woo SJ. Comparison of treatment methods for submacular hemorrhage in neovascular age-related macular degeneration: conservative versus active surgical strategy. Sci Rep 2022; 12:14875. [PMID: 36050401 PMCID: PMC9436992 DOI: 10.1038/s41598-022-18619-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/16/2022] [Indexed: 11/09/2022] Open
Abstract
The optimal treatment of submacular hemorrhage (SMH) following neovascular age-related macular degeneration (nAMD) is controversial. This study aimed to compare visual outcomes of conservative versus active surgical treatment. Two hundred thirty-six eyes of 236 patients with SMH (≥ 1 disc diameter) were stratified into four groups: observation (n = 21); anti-vascular endothelial growth factor (VEGF) monotherapy (n = 161); non-surgical gas tamponade (n = 31); and subretinal surgery (n = 23). The primary outcome was best-corrected visual acuity (BCVA) at 12 months. The baseline BCVAs of the observation, anti-VEGF monotherapy, non-surgical gas tamponade, and subretinal surgery groups were 1.50 ± 0.70, 1.09 ± 0.70, 1.31 ± 0.83, and 1.62 ± 0.77 logarithm of minimal angle resolution (LogMAR), respectively. The mean BCVAs at 12 months were 1.39 ± 0.84, 0.90 ± 0.83, 1.35 ± 0.88, and 1.44 ± 0.91 LogMAR, respectively. After adjusting for age, baseline BCVA, SMH size, and the number of intravitreal anti-VEGF injections before SMH, the mean BCVA showed no significant difference among treatments at 12 months (P = 0.204). The anti-VEGF monotherapy group showed better mean BCVA significantly at 3 months (P < 0.001). Only baseline BCVA was associated with VA gain at 12 months (Odds ratio = 3.53, P < 0.001). This study demonstrated that there was no difference in 12 month visual outcomes among treatments and a better early visual outcome can be expected with anti-VEGF monotherapy.
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Affiliation(s)
- Yongseok Mun
- Department of Ophthalmology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, 665-3, Siheung-daero, Yeongdeungpo-gu, Seoul, 07442, South Korea
| | - Kyu Hyung Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Sang Jun Park
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Han Joo Cho
- Department of Ophthalmology, Kim's Eye Hospital, 136, Yeongshin-ro, Yeongdeungpo-gu, Seoul, 07301, South Korea
| | - Chul Gu Kim
- Department of Ophthalmology, Kim's Eye Hospital, 136, Yeongshin-ro, Yeongdeungpo-gu, Seoul, 07301, South Korea
| | - Jong Woo Kim
- Department of Ophthalmology, Kim's Eye Hospital, 136, Yeongshin-ro, Yeongdeungpo-gu, Seoul, 07301, South Korea
| | - Dong Geun Park
- Department of Ophthalmology, Yeungnam University College of Medicine, 170, Hyunchung-ro, Nam-gu, Daegu, 42415, South Korea
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, 170, Hyunchung-ro, Nam-gu, Daegu, 42415, South Korea.
| | - Jae Hui Kim
- Department of Ophthalmology, Kim's Eye Hospital, 136, Yeongshin-ro, Yeongdeungpo-gu, Seoul, 07301, South Korea.
| | - Se Joon Woo
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
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19
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One-Year Outcome of Intravitreal Tissue Plasminogen Activator, Ranibizumab, and Gas Injections for Submacular Hemorrhage in Polypoidal Choroidal Vasculopathy. J Clin Med 2022; 11:jcm11082175. [PMID: 35456268 PMCID: PMC9032067 DOI: 10.3390/jcm11082175] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/26/2022] [Accepted: 04/12/2022] [Indexed: 12/10/2022] Open
Abstract
This study investigated one-year outcomes of treatment with one session of intravitreal recombinant tissue plasminogen activator, ranibizumab, and gas injections for submacular hemorrhage secondary to polypoidal choroidal vasculopathy (PCV). An extended study of a previous prospective trial of this treatment modality in PCV patients was conducted in 64 patients (64 eyes). Early Treatment Diabetic Retinopathy Study (ETDRS) score, central retinal thickness (CRT), and central pigment epithelial detachment thickness (CPEDT) before and 1, 3, and 12 months after treatment were analyzed. Mean ETDRS score increased from 58 at baseline to 64 letters (p = 0.0122), CRT decreased from 543 to 192 μm (p < 0.0001), and CPEDT decreased from 161 to 103 μm (p = 0.0668) at 3 months and were maintained until 12 months. Complications requiring reoperation occurred within one month in four eyes. Recurrence was observed in 46 eyes (72%), and 1.6 ± 1.5 (0−7) intravitreal aflibercept injections were given pro re nata. Univariate and multivariate analyses identified CPEDT as the pre- and post-treatment factor affecting 12-month ETDRS score (p < 0.0001). Improved visual acuity stabilized 3 months after treatment. Although 72% of patients experienced recurrence, an average of 1.6 aflibercept injections/patient maintained visual acuity up to 12 months. CPEDT was the most important factor associated with visual outcome.
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Fukuda Y, Nakao S, Kohno RI, Ishikawa K, Shimokawa S, Shiose S, Takeda A, Morizane Y, Sonoda KH. Postoperative follow-up of submacular hemorrhage displacement treated with vitrectomy and subretinal injection of tissue plasminogen activator: ultrawide-field fundus autofluorescence imaging in gas-filled eyes. Jpn J Ophthalmol 2022; 66:264-270. [PMID: 35260984 DOI: 10.1007/s10384-022-00910-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/28/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE To investigate the utility of Optos ultrawide-field fundus autofluorescence (UWF-FAF) imaging for postoperative follow-up of gas-filled eyes after vitrectomy with subretinal tissue-plasminogen activator (t-PA) injection for subretinal hemorrhage (SRH) displacement. STUDY DESIGN Retrospective consecutive case series. METHODS This study included 24 eyes with SRH. Vitrectomy with subretinal t-PA injection was performed, followed by postoperative prone positioning. FAF images acquired using Optos California were examined and the SRH occupancy in the macula was calculated. The main outcome measures were displacement rate and direction of SRH for 3 days postoperatively, and postoperative best-corrected visual acuity (BCVA). RESULTS The postoperative BCVA ranged from improvement (23 eyes; 95.8%) to no change (one eye; 4.2%). Analysis was done using postoperative Optos FAF images for 20 eyes (83.3%). Postoperative SRH occupancy was significantly reduced, by 27.4%, compared with the preoperative occupancy (P = 0.03). A statistically significant reduction was found between the preoperative and postoperative day (POD)1 (P = 0.04), but not between POD1 and POD2 (P = 0.7), or between POD2 and POD3 (P = 1.0). CONCLUSION UWF-FAF imaging is useful for postoperative follow-up of gas-filled eyes after vitrectomy with subretinal t-PA injection for SRH displacement.
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Affiliation(s)
- Yosuke Fukuda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Ophthalmology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan.,Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan
| | - Shintaro Nakao
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Ophthalmology, National Hospital Organization, Kyushu Medical Center, Fukuoka, Japan. .,Clinical Research Institute, National Hospital Organization, Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Ri-Ichiro Kohno
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keijiro Ishikawa
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sakurako Shimokawa
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Satomi Shiose
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Atsunobu Takeda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuki Morizane
- Department of Ophthalmology, Okayama University, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koh-Hei Sonoda
- Department of Ophthalmology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Macular Hemorrhage Due to Age-Related Macular Degeneration or Retinal Arterial Macroaneurysm: Predictive Factors of Surgical Outcome. J Clin Med 2021; 10:jcm10245787. [PMID: 34945083 PMCID: PMC8703651 DOI: 10.3390/jcm10245787] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: The study aimed to determine the outcomes and prognostic factors of vitrectomy, subretinal injection of tissue-plasminogen activator and gas tamponade in macular hemorrhage (MaH) due to age-related macular degeneration (AMD) or retinal arterial macroaneurysm (RAM). Methods: The study design utilized a multicentric retrospective case series design of consecutive patients undergoing surgery between 2014 and 2019. Results: A total of 65 eyes from 65 patients were included in the study. Surgery was performed after a mean period of 7.1 days. Displacement of MaH was achieved in 82% of the eyes. Mean best-corrected visual acuity (BCVA) improved from 20/500 to 20/125 at month(M)1 and M6 (p < 0.05). At M6, BCVA worsening was associated with an older age at diagnosis (p = 0.0002) and higher subretinal OCT elevation of MaH (p = 0.03). The use of treat and extend (TE) (OR = 16.7, p = 0.001) and small MaH fundus size (OR = 0.64 and 0.74 for horizontal and vertical fundus size, p < 0.05) were predictive of a higher likelihood of obtaining a countable BCVA at M1. Baseline BCVA was predictive of postoperative BCVA (p < 0.05). Retinal detachment and MaH recurrence occurred in 3% and 9.3% of cases at M6. Conclusion: MaH surgery stabilizes or improves BCVA in 85% of cases. Younger age at diagnosis, better baseline BCVA figures, smaller subretinal MaH height and use of TE regime were predictive of the best postoperative outcomes.
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22
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Long-Term Outcome of Eyes with Vitrectomy for Submacular and/or Vitreous Hemorrhage in Neovascular Age-Related Macular Degeneration. J Ophthalmol 2021; 2021:2963822. [PMID: 34765261 PMCID: PMC8577947 DOI: 10.1155/2021/2963822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To study long-term clinical outcomes in patients with submacular hemorrhage (SMH) and/or vitreous hemorrhage (VH) associated with neovascular age-related macular degeneration (nAMD) and the real-world clinical situation of adding anti-VEGF therapy after pars plana vitrectomy (PPV). Methods In this retrospective case series, 25 eyes with SMH and/or VH associated with nAMD were treated by PPV and followed up for at least 24 months. When exudative changes were unresolved or recurred after PPV, additional intravitreal anti-VEGF therapy was given. Results The reasons for performing PPV were SMH (8 eyes) and VH (17 eyes) associated with nAMD. Mean best-corrected visual acuity (BCVA) of eyes with SMH improved significantly at 6 months (P < 0.01) and 12 months (P < 0.05) after PPV. Mean BCVA of eyes with VH improved at 1, 3, 6, 12, 18, and 24 months (P < 0.01) and at the final visit (P < 0.05). Post-PPV anti-VEGF therapy was initiated in 6 of 8 (75.0%) eyes with SMH and 7 of 17 (47.1%) eyes with VH. Of the 13 eyes given anti-VEGF therapy after PPV, 11 eyes had anti-VEGF therapy initiated within 10 months after surgery. Dry macula rate after PPV was 50.0% in SMH and 70.6% in VH. Conclusions BCVA improved in eyes with SMH at 6 and 12 months after PPV, and the BCVA was maintained until the end of the study. BCVA improved significantly in eyes with VH at all time points after PPV. In eyes undergoing PPV for nAMD, recurrence of exudative changes after 11 months from the initial PPV was rare.
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Iannetta D, De Maria M, Bolletta E, Mastrofilippo V, Moramarco A, Fontana L. Subretinal Injection of Recombinant Tissue Plasminogen Activator and Gas Tamponade to Displace Acute Submacular Haemorrhages Secondary to Age-Related Macular Degeneration. Clin Ophthalmol 2021; 15:3649-3659. [PMID: 34483653 PMCID: PMC8409600 DOI: 10.2147/opth.s324091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/03/2021] [Indexed: 01/01/2023] Open
Abstract
Purpose To analyse the efficacy of subretinal injection of recombinant tissue plasminogen activator (rtPA) and gas tamponade for the displacement of submacular haemorrhage (SMH). Methods This single-centre, retrospective, case series included 25 consecutive patients (25 eyes) who underwent pars plana vitrectomy (PPV) with subretinal rtPA injection and 20% sulphur hexafluoride (SF6) tamponade. The primary outcome was SMH displacement rate, defined as the absence of subretinal blood within (complete) or outside (partial) 1500 μm centred on the fovea one month after PPV. Secondary outcomes were final best-corrected visual acuity (BCVA), central macular thickness (CMT), recurrence probability, number of anti-vascular endothelial growth factor (VEGF) injections after PPV, and intra- and post-operative complications. Results Successful displacement was obtained in all 25 eyes (100%), with complete and partial displacement obtained in 15 (60%) and 10 (40%), respectively. BCVA significantly improved from 1.81±0.33 to 1.37±0.52 LogMar at 12 months from surgery (p = 0.001). The bivariate correlation analysis revealed that earlier the surgery had better visual prognosis at the end of the follow-up (p = 0.007). CMT significantly decreased from 922 ± 273.69 µm at baseline to 403.53 ± 314.64 µm at 12 months follow-up (p < 0.001). SMH recurrence was observed in two (8%) patients with a mean survival time of 11.6 ± 0.339 months and a cumulative survival probability of 88% at the end of follow-up. After PPV, the mean number of anti-VEGF injections was 3.00 ± 0.957 with no correlation with final visual acuity (p = 0.365). No intraoperative complications were recorded. Only one patient developed open funnel retinal detachment 40 days after primary PPV. Conclusion PPV with rtPA subretinal injection and SF6 tamponade is a safe and effective technique in displacing acute SMHs secondary to neovascular AMD. It is recommended to perform within 14 days from the onset of the symptoms to achieve BCVA improvement at 12 months and proper imaging to plan future anti-VEG treatment.
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Affiliation(s)
- Danilo Iannetta
- Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Michele De Maria
- Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Elena Bolletta
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Antonio Moramarco
- Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luigi Fontana
- Ophthalmology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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24
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Matsuo Y, Haruta M, Ishibashi Y, Ishibashi K, Furushima K, Kato N, Murotani K, Yoshida S. Visual Outcomes and Prognostic Factors of Large Submacular Hemorrhages Secondary to Polypoidal Choroidal Vasculopathy. Clin Ophthalmol 2021; 15:3557-3562. [PMID: 34465976 PMCID: PMC8403222 DOI: 10.2147/opth.s327138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Patients with polypoidal choroidal vasculopathy (PCV) may develop large submacular hemorrhages (SMHs), which may result in severe visual loss. This study was performed to determine the visual outcomes and prognostic factors of large SMHs secondary to PCV. Patients and Methods We retrospectively reviewed the medical records of patients diagnosed with PCV who developed a large SMH. The best-corrected visual acuity (BCVA) data were collected at the SMH development, 1 month, 1 year after the SMH development, and at the final visit. Patients' medical information also were collected and included age, gender, systemic hypertension, current regular use of an anticoagulant or antiplatelet medication, the initial area of the SMH, breakthrough vitreous hemorrhage, ocular treatment, and fellow eye status. Univariate and multiple regression analyses were performed to determine the prognostic factors for the BCVA 1 year after the development of large SMHs. Results Thirty eyes of 29 patients were included in this study. The mean area of the SMHs at the development was 17.0 disc areas. The mean follow-up period after the development of SMHs was 53.5 months. The mean BCVA at the development, 1 month, and 1 year after the development, and at the final visit were 20/151, 20/263, 20/138, and 20/152, respectively. Multiple regression analyses indicated that a SMH 20 disc areas or larger was a significant negative factor, and the BCVA 1 month after the development was a significant positive factor affecting the BCVA 1 year after the development of large SMHs. Conclusion The increase in the initial area of SMH was correlated inversely with the BCVA 1 year after the development of SMH. The BCVA 1 month after the development may predict the BCVA 1 year after the development of a large SMH.
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Affiliation(s)
- Yu Matsuo
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Masatoshi Haruta
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Yumi Ishibashi
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Koki Ishibashi
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Kei Furushima
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | - Nobuhiro Kato
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
| | | | - Shigeo Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Japan
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25
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Comparison of subretinal versus intravitreal injection of recombinant tissue plasminogen activator with gas for submacular hemorrhage secondary to wet age-related macular degeneration: treatment outcomes and brief literature review. Int Ophthalmol 2021; 41:4037-4046. [PMID: 34331185 DOI: 10.1007/s10792-021-01976-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Contradictory evidence exists over the best approach for the management of submacular hemorrhage (SMH). In this study, we compared the outcomes of subretinal versus intravitreal injection of recombinant tissue plasminogen activator (r-tPA) and gas in cases of SMH secondary to age-related macular degeneration (AMD). METHODS Twenty five eyes with SMH were retrospectively divided in 2 groups. Group A underwent vitrectomy, subretinal r-tPA and gas (Vitrectomy group, n = 14), and group B received intravitreal r-tPA and gas (Pneumatic group, n = 11). SMH displacement and change in subfoveal hemorrhage thickness (SFHT) at 1 month post-op were assessed. Additionally, best corrected visual acuity (BCVA) and central retinal thickness (CRT) at the end of the 12 month follow-up (FU) were analyzed. Clinical and epidemiological prognostic factors were tested. RESULTS Mean duration of SMH prior intervention was 8.2(± 7.3) days. Baseline BCVA was 1.53 ± 0.73 LogMAR, mean extension of SMH was 4.604 ± 2079 μm and mean CRT pre-treatment was 795 ± 365 μm. SMH displacement at 1 month post-treatment was total in 9/14 versus 6/11 and partial in 4/14 versus 2/11 in Group A and Group B, respectively (Fisher's exact test p = 0.38). SFHT reduced by 404 ± 312 μm in Group A versus 376 ± 405 μm in group B (p = 0.86). BCVA improvement and reduction of CRT were highly significant at the end of FU (p = 0.002 and p < 0.001 respectively) but did not differ between the 2 groups. Only baseline BCVA and preoperative CRT proved to be significant prognostic factors for the final functional outcome (p = 0.013 and p = 0.047 respectively). CONCLUSION Both treatment options proved equal efficacy in displacing SMH in AMD. A multicenter trial may delineate a desirable algorithm of treatment.
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26
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Rickmann A, Paez LR, della Volpe Waizel M, Bisorca-Gassendorf L, Schulz A, Vandebroek AC, Szurman P, Januschowski K. Functional and structural outcome after vitrectomy combined with subretinal rtPA Injection with or without additional intravitreal Bevacizumab injection for submacular hemorrhages. PLoS One 2021; 16:e0250587. [PMID: 33930041 PMCID: PMC8087026 DOI: 10.1371/journal.pone.0250587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 04/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background To analyze the functional and anatomical outcome after vitrectomy with subretinal rtPA (recombinant tissue plasminogen activator) combined with or without an intravitreal Bevacizumab injection. Patients and methods Retrospective, consecutive case series of 31 pseudophakic patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (AMD) treated with vitrectomy, subretinal rtPA and pneumatic air displacement with or without an additional intravitreal Bevacizumab injection. The primary endpoints were best-corrected visual acuity (BCVA), and central macular thickness (CMT) measured by SD‑OCT. The secondary endpoint was a displacement of hemorrhage from the subretinal space three months after surgery. Results 31 eyes of 31 patients were treated with vitrectomy and subretinal rtPA. 17/31 were treated simultaneously with an intravitreal Bevacizumab injection (group +B) and 14/31 without (group -B). The mean visual acuity improved significantly in both groups (from 1.37±0.39 to 1.03±0.57 logMAR in +B and from 1.48±0.48 to 1.01±0.38 logMAR in group –B, p<0.05). The mean CMT decreased in group +B from 607±179 μm to 424±205 μm (p = 0.2) and in group –B from 722±216 μm to 460±202 μm (p<0.05). A central displacement of the hemorrhage could be achieved in 47% in group +B, whereas in group -B displacement could be achieved in 50% (p = 0.44). Conclusions Vitrectomy with subretinal rtPA injection and air tamponade with or without simultaneous intravitreal Bevacizumab injection displaces SMH and improves BCVA effectively. In comparison, the postoperative outcome is comparable regardless of whether or not intravitreal bevacizumab is applied simultaneously.
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Affiliation(s)
- Annekatrin Rickmann
- Depatment of Ophthalmology, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
- * E-mail:
| | - Lina R. Paez
- Depatment of Ophthalmology, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | | | | | - André Schulz
- Depatment of Ophthalmology, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | | | - Peter Szurman
- Depatment of Ophthalmology, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
| | - Kai Januschowski
- Depatment of Ophthalmology, Knappschaft Hospital Saar, Sulzbach/Saar, Germany
- Depatment of Ophthalmology, University Eye Clinic Tuebingen, Tuebingen, Germany
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27
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Iyer PG, Brooks HL, Flynn HW. Long-Term Favorable Visual Outcomes in Patients with Large Submacular Hemorrhage. Clin Ophthalmol 2021; 15:1189-1192. [PMID: 33776414 PMCID: PMC7987304 DOI: 10.2147/opth.s300662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/19/2021] [Indexed: 11/23/2022] Open
Abstract
Submacular hemorrhage (SMH) has been reported to be toxic to the retina based on animal studies. However, observational studies of patients with neovascular-related SMH and those treated with intravitreal anti-vascular growth factor (anti-VEGF) therapy have shown many favorable visual acuity outcomes. We report two cases of neovascular-related SMH with ten or more years of follow-up. The first case was an 83-year old female with a history of nonexudative age-related macular degeneration in both eyes presenting with sudden decrease in vision (20/400) in her right eye due to a large SMH, treated with anti-VEGF therapy. Over the next following months, there was resolution of the hemorrhage and return of good visual acuity. At 10-year follow-up, visual acuity was 20/30 in the right eye. The second case was a 49-year old female with a history of presumed ocular histoplasmosis syndrome (POHS), presenting with sudden vision loss (20/400) in her right eye due to large, thick SMH. With observation and intermittent anti-VEGF therapy, there was resolution of the hemorrhage. At 30-year follow-up, visual acuity was 20/20 in the right eye.
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Affiliation(s)
- Prashanth G Iyer
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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28
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Avcı R, Mavi Yıldız A, Çınar E, Yılmaz S, Küçükerdönmez C, Akalp FD, Avcı E. Subretinal Coapplication of Tissue Plasminogen Activator and Bevacizumab with Concurrent Pneumatic Displacement for Submacular Hemorrhages Secondary to Neovascular Age-Related Macular Degeneration. Turk J Ophthalmol 2021; 51:38-44. [PMID: 33631914 PMCID: PMC7931654 DOI: 10.4274/tjo.galenos.2020.72540] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives To evaluate the functional and morphological outcomes of vitrectomy in combination with intravitreal 5% C3F8 tamponade and subretinal injections of tissue plasminogen activator (tPA) and anti-vascular endothelial growth factor (anti-VEGF) in patients with submacular hemorrhage (SMH) and to investigate the preoperative prognostic factors. Materials and Methods This retrospective study included 30 patients (16 women, 14 men) diagnosed with SMH secondary to neovascular age-related macular degeneration (AMD). Preoperative SMH thickness and area, ellipsoid zone integrity, and postoperative reduction in the amount of subfoveal blood on optical coherence tomography and fundus photographs were assessed. Furthermore, visual acuity (VA), hemorrhage duration, and the need for additional intravitreal anti-VEGF injections were recorded. Results The patients' mean age was 73.33±8.23 years. Mean VA improved from logMAR 2.11±0.84 at baseline to logMAR 1.32±0.91, 0.94±0.66, 1.13±0.84, and 1.00±0.70 at postoperative month 1, 2, 3, and 6, respectively. A significant negative correlation was found between hemorrhage duration and postoperative VA at month 2 (p=0.005), month 3 (p=0.019), and month 6 (p=0.012). The mean preoperative SMH duration was significantly shorter in patients who achieved total resolution of the hemorrhage compared with the subtotal resolution group (p<0.001). The mean SMH area was smaller in the patients with continuous ellipsoid zone. Conclusion Vitrectomy and submacular tPA and anti-VEGF injections with concurrent C3F8 tamponade appears to provide adequate displacement of the hemorrhage, resulting in significant VA improvement in patients with hemorrhagic neovascular AMD. Timing of the surgery appears to be the most important factor determining the final VA.
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Affiliation(s)
- Remzi Avcı
- Bursa Retina Eye Hospital, Bursa, Turkey
| | | | | | | | | | | | - Emre Avcı
- Acıbadem University Faculty of Medicine, İstanbul, Turkey
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29
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Tan GSW, Liu Z, Ilmarinen T, Barathi VA, Chee CK, Lingam G, Su X, Stanzel BV. Hints for Gentle Submacular Injection in Non-Human Primates Based on Intraoperative OCT Guidance. Transl Vis Sci Technol 2021; 10:10. [PMID: 33510949 PMCID: PMC7804573 DOI: 10.1167/tvst.10.1.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/02/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose Delivery of Advanced Therapy Medicinal Products to the submacular space is increasingly evolving into a therapeutic modality. Cell replacement for age-related macular degeneration (AMD) and gene therapy for RPE65 are recent successful examples. Herein, a nonhuman primate (NHP) model was used to investigate surgical means to detach the macula. Methods Sixteen eyes of 13 healthy macaques underwent a 25-gauge vitrectomy and subretinal injection of balanced salt solution monitored by microscope-integrated intraoperative optical coherence tomography (miOCT). The animals were followed with OCT and histology. Results The miOCT monitoring allowed a more precise definition of surgical trauma ranging from an initial full-thickness foveal tear, or induction of a cystoid macular edema (CME), until no foveal defect was discernible, as the technique improved. However, as the subretinal fluid wave detached the fovea, the aforementioned lesions formed, whereas persistent retinal adhesion reproducibly proved to remain in the distal parafoveal semi-annulus. Measures to reduce foveal trauma during submacular fluid injection included reducing intraocular pressure, injection volume, and velocity, as well as the retinal location for bleb initiation, use of a vitreous tamponade, and a dual-bore subretinal cannula. Conclusions A stable very low intraocular pressure and careful subretinal injection may avoid tangential macular stretching or mechanical CME formation, while vitreous tamponade may facilitate a more lamellar subretinal flow, all thereby reducing foveal trauma during submacular injection in NHP. Translational Relevance These results can be relevant to any submacular surgery procedure used today, as they synergistically reduce the risk of compromising foveal integrity.
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Affiliation(s)
- Gavin S W Tan
- Singapore National Eye Centre, Singapore, Singapore.,Singapore Eye Research Institute, Singapore, Singapore.,Ophthalmology Academic Clinical Research Program, DUKE-NUS Medical School, Singapore, Singapore
| | - Zengping Liu
- Singapore Eye Research Institute, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Institute of Molecular and Cell Biology, ASTAR (Agency for Science, Technology and Research), Singapore, Singapore
| | - Tanja Ilmarinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Veluchamy A Barathi
- Singapore Eye Research Institute, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Ophthalmology Academic Clinical Research Program, DUKE-NUS Medical School, Singapore, Singapore
| | - Caroline K Chee
- Singapore Eye Research Institute, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Ophthalmology, National University Hospital, Singapore, Singapore
| | - Gopal Lingam
- Singapore Eye Research Institute, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Ophthalmology, National University Hospital, Singapore, Singapore
| | - Xinyi Su
- Singapore Eye Research Institute, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Institute of Molecular and Cell Biology, ASTAR (Agency for Science, Technology and Research), Singapore, Singapore.,Department of Ophthalmology, National University Hospital, Singapore, Singapore
| | - Boris V Stanzel
- Singapore National Eye Centre, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Eye Clinic Sulzbach, Knappschaft Hospital Saar, Sulzbach, Saar, Germany
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Lim JH, Han YS, Lee SJ, Nam KY. Risk factors for breakthrough vitreous hemorrhage after intravitreal tissue plasminogen activator and gas injection for submacular hemorrhage associated with age related macular degeneration. PLoS One 2020; 15:e0243201. [PMID: 33270725 PMCID: PMC7714180 DOI: 10.1371/journal.pone.0243201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 11/18/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose We investigated risk factors for breakthrough vitreous hemorrhage (VH) after an intravitreal tissue plasminogen activator (tPA) and gas injection in patients with submacular hemorrhage (SMH) associated with age-related macular degeneration (AMD). Methods The medical records of patients diagnosed with SMH associated with AMD who received an intravitreal tPA (50 μg/0.05 mL) and perfluoropropane gas (0.3 mL) injection were reviewed retrospectively. We analyzed the associations of breakthrough VH with age, sex, best-corrected visual acuity, intraocular pressure, AMD subtype, accompanying sub-retinal pigment epithelium (RPE) hemorrhage, history of cataract surgery, history of hypertension and diabetes mellitus, history of drinking and smoking, and history of antiplatelet or anticoagulant medication. We also examined the relationships between various parameters, including the area ratio of the SMH to the optic disc (AHD) and the height of the SMH obtained from optical coherence tomography. Results In total, 52 eyes from 52 patients were enrolled in this study; 16 eyes (30%) showed breakthrough VH. The proportions of patients with a current smoking history were 75.0% in the VH group and 22.2% in the non-VH group (p = 0.010). Other factors did not differ significantly between the two groups. The proportion of cases with accompanying sub-RPE hemorrhage was 50.0% and 58.3% in the VH and non-VH groups, respectively (p = 0.763). The AHD (p = 0.001) and SMH height (p < 0.001) were significantly greater in the VH group. In a receiver operating characteristic curve analysis, the cut-off values of AHD and SMH height were 20.1 and 1208 μm, respectively. According to logistic regression analysis, when the AHD and SMH height were greater than the individual cut-off values, the odds ratio of VH increased by 10.286 fold (95% confidence interval [CI], 2.452–43.148; p = 0.001) and 75.400 fold (95% CI, 7.991–711.441; p < 0.001), respectively, with respect to their respective reference groups (less than the cut-off value). Among the significant factors associated with VH occurrence, including current smoking, AHD, and SMH height, only current smoking and SMH height were found to be significant in multiple regression analysis (p = 0.040, 0.016). Conclusions The incidence of breakthrough VH was significantly higher in those with current smoking status and for SMH with a larger AHD and greater height. The height of the SMH was more predictable of the possibility of VH than AHD.
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Affiliation(s)
- Jun Hyun Lim
- Department of Ophthalmology, Kosin University Hospital, Busan, South Korea
| | - Yong Seop Han
- Department of Ophthalmology, College of Medicine, Gyeonsang National University, Jinju, South Korea
- Department of Ophthalmology, Gyeonsang National University Changwon Hospital, Changwon, South Korea
| | - Sang Joon Lee
- Department of Ophthalmology, Kosin University Hospital, Busan, South Korea
- Department of Ophthalmology, College of Medicine, Kosin University, Busan, South Korea
| | - Ki Yup Nam
- Department of Ophthalmology, Gyeonsang National University Changwon Hospital, Changwon, South Korea
- Department of Ophthalmology, College of Medicine, Chungnnam National University, Daejeon, South Korea
- * E-mail:
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Fibrovascular pigment epithelial detachment in eyes with subretinal hemorrhage secondary to neovascular AMD or PCV: a morphologic predictor associated with poor treatment outcomes. Sci Rep 2020; 10:14943. [PMID: 32913279 PMCID: PMC7483711 DOI: 10.1038/s41598-020-72030-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022] Open
Abstract
To evaluate the influence of fibrovascular pigment epithelial detachment (FVPED) on treatment outcomes in eyes with subretinal hemorrhage secondary to neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). This retrospective study included 83 eyes diagnosed with fovea-involving submacular hemorrhage secondary to neovascular AMD or PCV. All the patients were treated with intravitreal anti-vascular endothelial growth factor. Eyes showing definite FVPED, which involves the subfoveal region, were included in the FVPED group. Eyes without subfoveal PED, shallow irregular PEDs, or serous/hemorrhagic PED were stratified to the non-FVPED group. The best-corrected visual acuity (BCVA) at diagnosis, at 3 months, at 12 months, and lesion re-activation after initial treatment were compared between the two groups. The mean size of hemorrhage was 8.6 ± 7.6 disc diameter areas. In the FVPED group, the mean logarithm of minimal angle of resolution BCVA was 1.11 ± 0.49 at diagnosis, 0.89 ± 0.58 at 3 months, and 1.05 ± 0.63 at 12 months. In the non-FVPED group, the values were 0.97 ± 0.56, 0.56 ± 0.55, and 0.45 ± 0.50, respectively. The BCVA at 3 months (P = 0.036) and at 12 months (P < 0.001) was significantly worse in the FVPED group than in the non-FVPED group. In addition, the incidence of lesion reactivation was greater in the FVPED group (83.3%) than in the non-FVPED group (38.5%) (P < 0.001). The presence of subfoveal FVPED was associated with a high incidence of lesion re-activation and poor treatment outcomes in eyes with subretinal hemorrhage. This result suggests that different treatment strategies are needed between eyes with and without FVPED.
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The Timing of Large Submacular Hemorrhage Secondary to Age-Related Macular Degeneration Relative to Anti-VEGF Therapy. Ophthalmol Retina 2020; 5:342-347. [PMID: 32763426 DOI: 10.1016/j.oret.2020.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/25/2020] [Accepted: 07/28/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE To characterize the timing of large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD) relative to anti-vascular endothelial growth factor (VEGF) therapy. DESIGN Retrospective, consecutive case series. PARTICIPANTS The study included 46 eyes of 46 patients with large SMH resulting from neovascular AMD selected to undergo pars plana vitrectomy with subretinal tissue plasminogen activator at the Mid Atlantic Retina group of the Wills Eye Hospital. METHODS Patient charts were reviewed to identify baseline characteristics and anti-VEGF treatment details. OCT was used to evaluate pigmented epithelial detachments, SMH, and subretinal fluid before and after SMH. MAIN OUTCOME MEASURES The timing of SMH in relation to last anti-VEGF injection, the anti-VEGF treatment status (i.e., naive, stable, or recently extended or shortened) at the time of SMH, and the length of the anti-VEGF treatment interval at the time of bleeding. RESULTS Submacular hemorrhage occurred in 15 patients (36%) who were treatment naive. In patients treated with anti-VEGF, 19 (45%) had a stable treatment interval, 5 (12%) had a recently extended interval, and 3 (7%) had a shortened interval. The average treatment interval at the time of SMH was 6.8 weeks with a median of 7 total injections before SMH. Seven treated patients (26%) experience an SMH while having a 4-week dosing interval. The average time between last injection and SMH was 29 days. Forty-eight percent of patients treated with anti-VEGF agents experienced an SMH within 30 days of anti-VEGF injection. Chi-square analysis found SMH more likely to occur within 30 days of anti-VEGF injection than after 30 days. CONCLUSIONS Large SMH in neovascular AMD in a treat-and-extend regimen does not seem to be associated with prolonged dosing intervals or recent interval extension, and a large proportion of such hemorrhages are likely to be a result of mechanisms other than loss of effective VEGF inhibition.
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[Management of submacular hemorrhage : What, when, how?]. Ophthalmologe 2020; 117:848-857. [PMID: 32767098 DOI: 10.1007/s00347-020-01192-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Subretinal hemorrhage involving the macula is a typical complication in a variety of retinal diseases, whereby age-related macular degeneration (AMD) is by far the leading cause. METHOD A literature search was carried out in PubMed. RESULTS Numerous studies have demonstrated the effectiveness of various approaches to the management of submacular hemorrhage, including intravitreal anti-VEGF treatment, pneumatic displacement supported by fibrinolytic agents or surgical drainage. DISCUSSION There is currently no consensus regarding evidence-based standard treatment for macular hemorrhage, although there is a trend towards minimally invasive approaches. Regardless of the choice of the primary treatment approach, the time to treatment and an accompanying intravitreal treatment with VEGF inhibitors are decisive for the functional outcome.
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Intraocular Pharmacokinetics and Safety of Subretinal Injection Compared with Intravitreal Application of Conbercept in Vitrectomized Rabbit Eyes. J Ophthalmol 2020; 2020:2674780. [PMID: 32280518 PMCID: PMC7125476 DOI: 10.1155/2020/2674780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 09/27/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the ocular pharmacokinetic properties of subretinal conbercept injection in vitrectomized rabbit eyes and to compare them with those by intravitreal injection. Methods The following groups of New Zealand white rabbits received conbercept injections (0.5 mg/0.05 ml): a subretinal group (subretinal injection in vitrectomized eyes), an intravitreal group (intravitreal injection in vitrectomized eyes), and a control group (intravitreal injection in nonvitrectomized eyes). Drug concentrations in the aqueous humor (AH), the vitreous humor (VH), and the retina were measured by the enzyme-linked immunosorbent assay (ELISA), and pharmacokinetic parameters were calculated. Ophthalmic B-ultrasonography, electroretinogram (ERG), and hematoxylin and eosin (H&E) staining were performed to evaluate the safety of subretinal injection. Results On the 28th day after injection, the drug level in the subretinal group was significantly higher than that in the intravitreal group in the AH (0.90 ± 0.25 μg/ml and 0.11 ± 0.07 μg/ml and 0.11 ± 0.07 P < 0.001, respectively) and the VH (5.00 ± 3.86 μg/ml and 0.11 ± 0.07 μg/ml and 0.11 ± 0.07 P < 0.001, respectively) and the VH (5.00 ± 3.86 P < 0.001, respectively) and the VH (5.00 ± 3.86 P < 0.001, respectively) and the VH (5.00 ± 3.86 Conclusions Our study indicates that applying conbercept by subretinal injection can reduce the drug clearance rate and sustain a long maintenance period in ocular tissue, which suggests that subretinal conbercept injection may be a potentially valuable treatment option.
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35
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Wilkins CS, Mehta N, Wu CY, Barash A, Deobhakta AA, Rosen RB. Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage. BMJ Open Ophthalmol 2020; 5:e000394. [PMID: 32201733 PMCID: PMC7076260 DOI: 10.1136/bmjophth-2019-000394] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/13/2020] [Accepted: 02/19/2020] [Indexed: 11/22/2022] Open
Abstract
Objective Fovea-involving subretinal haemorrhage is challenging to manage with uncertain visual outcomes. We reviewed outcomes of patients with fovea-involving macular haemorrhage treated with pars plana vitrectomy (PPV) and subretinal tissue plasminogen activator (tPA) with pneumatic displacement. Methods and Analysis This is a retrospective interventional case series. All patients with submacular haemorrhage who underwent PPV with subretinal tPA injection were included. Reasons for exclusion encompassed patients who underwent intravitreal tPA injection in the office without surgery, insufficient follow-up or documentation. Primary outcomes of interest were postoperative visual acuity (VA) at month 1 and 3. Secondary outcomes were median VA at month 3 by location of haemorrhage and underlying diagnosis. Results Thirty-seven total patients were included. The mean age was 68.2 years, with 54.1% (20/37) females. The most common aetiology was exudative macular degeneration (43.2%), followed by undifferentiated choroidal neovascularisation (CNV) (18.9%), polypoidal choroidal vasculopathy (18.9%), traumatic CNV (10.8%), macroaneurysm (5.4%) and proliferative diabetic retinopathy (2.7%). Median preoperative VA was 20/2000, postoperative month 1 was 20/347 (p<0.01), improving to 20/152 (p<0.01) at month 3. Proportion of patients gaining vision 3+ lines in vision was 15/36 (42%). Mean preoperative central subfield thickness on optical coherence tomography was 512.2 µm for sub-retinal pigment epithelium haemorrhage and 648.2 µm for subretinal haemorrhage (p=0.48). Difference in VA by diagnosis was not significant (p=0.60). Conclusions PPV with subretinal tPA injection and pneumatic displacement of submacular haemorrhage offers modest visual recovery for a diverse group of patients. Location of haemorrhage or specific diagnosis may not predict outcome.
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Affiliation(s)
- Carl S Wilkins
- New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Neesurg Mehta
- New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Chris Y Wu
- New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | - Alexander Barash
- New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
| | | | - Richard B Rosen
- New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA
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Berthon C, Rousseau E, Chiambaretta F. [Treatment of submacular hematoma by vitrectomy, subretinal injection of rtPA and gaseous tamponade: A single-center retrospective observational study]. J Fr Ophtalmol 2020; 43:417-426. [PMID: 32192752 DOI: 10.1016/j.jfo.2019.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/20/2019] [Accepted: 09/24/2019] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the functional and anatomic recovery of submacular hemorrhage (SMH), treated with vitrectomy, subretinal injection of rtPA and gas tamponade, to highlight the risk factors for their occurrence as well as the factors influencing prognosis. MATERIALS AND METHODS This is a single-center retrospective study. Thirty-two eyes of 30 patients from the Clermont-Ferrand University Hospital were included, with a submacular hemorrhage (SMH) requiring surgical evacuation. The primary endpoint was final postoperative visual recovery. Visual acuities (AV) were converted to the logarithmic minimum angle of resolution scale (logMAR) for statistical analysis. RESULTS The average time from onset of symptoms to surgery was 4.8±3.3 days. The initial VA was 2.1±0.3 logMAR, with an average improvement of 0.7±0.7 logMAR (P=0.0004) at the final visit. The mean thickness of the SMH decreased by 729±352μm (P<0.0001) at the final visit. CONCLUSION Treatment of SMH with vitrectomy, subretinal injection of rtPA and gas tamponade results in a statistically significant improvement in final VA, as well as a significant decrease in SMH thickness on OCT.
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Affiliation(s)
- C Berthon
- CHU de Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France.
| | - E Rousseau
- CHU de Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
| | - F Chiambaretta
- CHU de Gabriel Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand, France
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Lu AQ, Prensky JG, Baker PS, Scott IU, Mahmoud TH, Todorich B. Update on medical and surgical management of submacular hemorrhage. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1725474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Amy Q. Lu
- Department of Ophthalmology, Penn State College of Medicine, Hershey, PA, USA
| | | | | | - Ingrid U. Scott
- Department of Ophthalmology, Penn State College of Medicine, Hershey, PA, USA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Tamer H. Mahmoud
- Department of Ophthalmology, Oakland University William Beaumont School of Medicine, and Associated Retinal Consultants, PC, Royal Oak, MI, USA
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Maggio E, Peroglio Deiro A, Mete M, Sartore M, Polito A, Prigione G, Guerriero M, Pertile G. Intravitreal Recombinant Tissue Plasminogen Activator and Sulphur Hexafluoride Gas for Submacular Haemorrhage Displacement in Age-Related Macular Degeneration: Looking behind the Blood. Ophthalmologica 2020; 243:224-235. [PMID: 31905361 DOI: 10.1159/000505752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/06/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the effectiveness of recombinant tissue plasminogen activator (rtPA) and sulphur hexafluoride gas (SF6) intravitreal injection for the displacement of large submacular haemorrhages (SMH) secondary to neovascular age-related macular degeneration and for guiding the selection of additional treatments or observations for choroidal neovascularization (CNV). METHODS The medical records of consecutive patients with recent-onset, large SMH, treated at Sacro Cuore Hospital from January 2004 to May 2016, were retrospectively analysed. All eyes underwent a 0.05-mL intravitreal injection of 50 μg rtPA, 0.3 mL of 100% SF6, and then face-down positioning. Afterwards, the eyes received additional treatments for CNV or observation, based on the severity and extent of the underlying pathology. The multimodal imaging features revealed after blood displacement were analysed and then correlated to the treatment selected as a second therapeutic option. RESULTS A total of 96 eyes met the inclusion criteria and was evaluated in this study. SMH was displaced from the fovea in the majority of the eyes (76%), allowing several diagnostic tools to evaluate the underlying macular features. In 19 cases (19.8%) exhibiting severe macular damage, no additional treatment was applied. In the remaining eyes, subsequent treatments included anti-vascular endothelial growth factor injections (44.8%), photodynamic therapy (n = 2), and submacular surgery (35.4%). Statistically significant correlations were found between the macular findings revealed after blood displacement and the additional treatments or observations selected for the underlying disease. The mean follow-up was 35 months. Improvements in visual acuity were statistically significant up to 3 years. CONCLUSION Intravitreal rtPA and gas injection was found to be effective for the displacement of large SMH, allowing postoperative diagnostic testing, and thus guiding the opportunity to apply further treatments. The addition of subsequent individualized treatments may allow long-term visual gain in selected cases.
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Affiliation(s)
- Emilia Maggio
- Ophthalmology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy,
| | | | - Maurizio Mete
- Ophthalmology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Mauro Sartore
- Ophthalmology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Antonio Polito
- Ophthalmology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Guido Prigione
- Ophthalmology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | | | - Grazia Pertile
- Ophthalmology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
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Wong DT, Lambrou GN, Loewenstein A, Pearce I, Okada AA. SUSPENDING TREATMENT OF NEOVASCULAR AGE-RELATED MACULAR DEGENERATION IN CASES OF FUTILITY. Retina 2019; 40:1010-1020. [PMID: 31876889 PMCID: PMC7448759 DOI: 10.1097/iae.0000000000002713] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide guidance on the management of patients with neovascular age-related macular degeneration and its subtypes who respond poorly to anti-vascular endothelial growth factor (anti-VEGF) therapy, and to identify cases where suspending anti-VEGF treatment may be warranted. METHODS Through a literature review and the combined knowledge and clinical experience of retinal experts, the Steering Committee of the Bayer-sponsored Vision Academy developed an algorithm for determining when to suspend anti-VEGF treatment of neovascular age-related macular degeneration in cases of futility. RESULTS Consideration of factors that may cause suboptimal response to anti-VEGF therapy, such as undertreatment or misdiagnosis of the underlying condition, and factors that may preclude continued treatment, such as injection- or drug-induced complications, is necessary for adjusting treatment protocols in patients who respond poorly to anti-VEGF. If poor response to treatment persists after switching to an alternative anti-VEGF agent and no change in response is observed after withholding treatment for a predetermined period of time ("treatment pause"), anti-VEGF treatment may be considered futile and should be suspended. CONCLUSION This publication introduces an algorithm to guide the management of neovascular age-related macular degeneration in patients showing poor response to anti-VEGF treatment and provides expert guidance for suspending anti-VEGF treatment in cases of futility.
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Affiliation(s)
- David T Wong
- University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | | | - Anat Loewenstein
- Department of Ophthalmology, Tel Aviv Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ian Pearce
- Royal Liverpool University Hospital, Liverpool, United Kingdom; and
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Boiché M, Angioi-Duprez K, Conart JB, Berrod JP. [Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results (French translation of the article)]. J Fr Ophtalmol 2019; 43:43-50. [PMID: 31870667 DOI: 10.1016/j.jfo.2019.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/03/2019] [Accepted: 02/19/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate anatomical and functional outcomes of surgical displacement of macular hemorrhages complicating exsudative age-related macular degeneration (AMD) after vitrectomy, subretinal rtPA (recombinant tissue plasminogen activator) injection, intravitreal bevacizumab injection and gaz tamponade. METHODS Retrospective case series, including 26 patients with submacular hemorrhage, who underwent a surgical displacement within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was carried out to measure the diameter of the hemorrhage and to specify the relation with retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage away from the fovea at first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit. RESULTS The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5,8 (±7,2) lines (P=0.0003) at 1 month postoperatively, 7,4 (±6,7) lines (P=0.0004) at 6 months and 7,4 (±7,4) lines (P=0.0002) at final postoperative visit (16,5±19,8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient P=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)). CONCLUSION Vitrectomy with subretinal rtPA injection was found to be effective for the displacement of AMD hemorrhage in 81 % of the patients. Mean final visual acuity improved by more than 7 lines.
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Affiliation(s)
- M Boiché
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandoeuvre-lès-Nancy.
| | - K Angioi-Duprez
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandoeuvre-lès-Nancy
| | - J-B Conart
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandoeuvre-lès-Nancy
| | - J-P Berrod
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandoeuvre-lès-Nancy
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Li ZX, Hu YJ, Atik A, Lu L, Hu J. Long-term observation of vitrectomy without subretinal hemorrhage management for massive vitreous hemorrhage secondary to polypoidal choroidal vasculopathy. Int J Ophthalmol 2019; 12:1859-1864. [PMID: 31850169 DOI: 10.18240/ijo.2019.12.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 06/25/2019] [Indexed: 11/23/2022] Open
Abstract
AIM To describe the long-term observation of vitrectomy without subretinal hemorrhage (SRH) management for massive vitreous hemorrhage (VH) secondary to polypoidal choroidal vasculopathy (PCV). METHODS This is a retrospective, consecutive case series. A total of 86 eyes of 86 patients with >14d of massive VH associated with PCV were included. All patients underwent vitrectomy without SRH management, followed by intravitreal ranibizumab injections and/or photodynamic therapy (PDT) as needed. The main outcome measures were best-corrected visual acuity (BCVA), postoperative adverse events and the recurrence of VH. RESULTS The average follow-up period was 25.5±9.2mo (range 12-35mo). Mean BCVA at baseline (2.16±0.39 logMAR) had improved significantly, both 3mo after surgery (1.42±0.66 logMAR, P<0.001) and by the last visit (1.23±0.74 logMAR, P<0.001). The common postoperative complications included macular subretinal fibrosis in 14 eyes (16.3%) and ciliary body detachment in 4 eyes (4.7%). Nineteen eyes (22.1%) received following treatment with ranibizumab injections without/with PDT, and 15 (17.4%) were resolved. Four eyes (4.7%) had recurrent hemorrhage during the follow-up period. In multiple regression analysis, thicker SRH (beta=0.33, P=0.025) in the preoperative B-scan and the presence of foveal subretinal fibrosis (beta=0.28, P=0.018) in the follow up were associated with poor postoperative BCVA. CONCLUSION Vitrectomy without SRH management for massive VH secondary to PCV improved/stabilized visual function in the long-term observation. Eyes presenting with thicker SRH preoperatively and forming foveal subretinal fibrosis in the follow-up period tended to have worse BCVA.
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Affiliation(s)
- Zhi-Xi Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Yi-Jun Hu
- Aier School of Ophthalmology, Central South University, Changsha 410000, Hunan Province, China
| | - Alp Atik
- Royal Victorian Eye and Ear Hospital, Melbourne 3000, Australia
| | - Lin Lu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Jie Hu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
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Sniatecki JJ, Ho-Yen G, Clarke B, Barbara R, Lash S, Papathomas T, Antonakis S, Gupta B. Treatment of submacular hemorrhage with tissue plasminogen activator and pneumatic displacement in age-related macular degeneration. Eur J Ophthalmol 2019; 31:643-648. [PMID: 31813290 DOI: 10.1177/1120672119891625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate visual and anatomic outcomes following pars plana vitrectomy and intravitreal or subretinal tissue plasminogen activator for submacular hemorrhage in patients with age-related macular degeneration. METHODS This was a retrospective study on patients with a minimum follow-up of 12 months undertaken at a tertiary referral center. Data collected include demographic details, visual and optical coherence tomography changes, surgical details, and complications. Surgical results were compared with patients who were age and lesion size matched and treated with anti-vascular endothelial growth factor injections alone. RESULTS There were 36 patients in surgical and 18 patients in control group. Patients in surgical arm had pars plana vitrectomy, intravitreal tissue plasminogen activator with air 24 (67%), 6 (16%) with C3F8 gas, 1 (3%) with SF6 gas, 4 (11%) subretinal tissue plasminogen activator with air, and 1 (3%) with C2F6 as post-operative tamponade. Mean LogMAR in tissue plasminogen activator group at baseline was 1.56, and it was improved at all time points 1.06 at 1 month (p < 0.05), 0.91 at 6 months (p < 0.05), and 1.07 at 1 year (p < 0.05). Mean best corrected visual acuity in control group at baseline was 1.22LogMAR with no significant improvement at any time points: 1 month (1.27), 6 months (1.35), and 12 months (1.36). Complications included retinal detachment 5%, vitreous hemorrhage 7.5%, and cataract 19%. CONCLUSION Pars plana vitrectomy with intravitreal (or subretinal) tissue plasminogen activator and pneumatic displacement can offer better outcome in comparison to anti-vascular endothelial growth factor alone in patients with submacular hemorrhage secondary to age-related macular degeneration.
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Affiliation(s)
| | - Gregory Ho-Yen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Benjamin Clarke
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ramez Barbara
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stephen Lash
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Thomas Papathomas
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Bhaskar Gupta
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Boiché M, Angioi-Duprez K, Conart JB, Berrod JP. Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results. J Fr Ophtalmol 2019; 42:e391-e397. [PMID: 31471124 DOI: 10.1016/j.jfo.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/20/2019] [Accepted: 07/26/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Macular subretinal hematoma is a complication of age related macular degeneration (AMD) responsible for a severe change in vision. We evaluated anatomic and functional results of surgical treatment of hematoma by vitrectomy, subretinal injection of r-tPA (recombinant tissue plasminogen activator), intravitreal bevacizumab injection and air tamponade. METHODS Retrospective case series including 26 patients with submacular hemorrhage who underwent vitrectomy within 15 days after the onset of symptoms. Optical coherence tomography (OCT) was performed to measure the diameter of the hemorrhage and specify the location in relation to the retinal pigment epithelium. Anatomical success was defined as a total displacement of the hemorrhage out of the fovea at the first postoperative visit. Visual acuity improvement was measured at 1 and 6 months and at final postoperative visit. RESULTS The procedure resulted in hemorrhage displacement away from the fovea in 20 eyes (81%). Visual acuity significantly improved by 5.8 (±7.2) lines (P=0.0003) at 1 month postoperatively, 7.4 (±6.7) lines (P=0.0004) at 6 months and 7.4 (±7.4) lines (P=0.0002) at the final postoperative visit (16.5±19.8 months). There was an inverse correlation between hemorrhage diameter and final acuity improvement (Pearson correlation coefficient ρ=-0.60 (IC 95% [-0.81; -0.26]; P=0.002)). CONCLUSION Vitrectomy with subretinal r-tPA injection was found to be effective for the displacement of AMD hemorrhage in 81% of the patients. Mean final visual acuity improved by more than 7 lines, confirming the efficacy and functional benefit of surgical displacement.
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Affiliation(s)
- M Boiché
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France.
| | - K Angioi-Duprez
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - J-B Conart
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
| | - J-P Berrod
- Department of ophthalmology, CHRU Nancy-Brabois, rue du Morvan, 54500 Vandœuvre-lès-Nancy, France
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Obeid A, Talcott KE, Ali FS, Gao X, Sioufi K, Wibbelsman TD, Ho AC. Macular Hole Following Subretinal Tissue Plasminogen Activator for Submacular Hemorrhage Secondary to Neovascular AMD. Ophthalmic Surg Lasers Imaging Retina 2019; 50:e257-e259. [PMID: 31589767 DOI: 10.3928/23258160-20190905-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/26/2019] [Indexed: 11/20/2022]
Abstract
A full-thickness macular hole (FTMH) is a rare sequela to submacular hemorrhage. Herein, the authors report a case of an 80-year-old man actively being treated for neovascular age-related macular degeneration who presented with sudden vision loss in the right eye. Examination with optical coherence tomography (OCT) imaging revealed submacular hemorrhage. The patient underwent vitrectomy with subretinal tissue plasminogen activator (tPA) with no intraoperative complications. Dilated fundus examination and OCT imaging revealed a FTMH at postop week 1. Possible causes for MH development include the submacular hemorrhage itself and subretinal administration of the tPA infusion. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e257-e259.].
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Kaga T, Kojima T, Yokoyama S, Sato H, Yoshida N, Ichikawa K. SUBRETINAL ENDOSCOPIC SURGERY TO TREAT LARGE SUBRETINAL HEMORRHAGES SECONDARY TO AGE-RELATED MACULAR DEGENERATION. Retina 2019; 39:896-905. [DOI: 10.1097/iae.0000000000002031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Treatment of macular hemorrhage in retinal arterial microaneurysm: anatomic site-oriented therapy. Jpn J Ophthalmol 2019; 63:186-196. [PMID: 30783941 DOI: 10.1007/s10384-019-00653-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE To investigate the usefulness of anatomic site-oriented therapy for macular hemorrhage secondary to retinal arterial macroaneurysm (RAM). STUDY DESIGN Retrospective observational study, clinical case series METHODS: Twenty-seven consecutive patients (27 eyes) with macular hemorrhage secondary to RAM were classified according to the retinal layer(s) with hemorrhage identified by optical coherence tomography into 4 types and treated differentially. Vitrectomy was conducted for subinternal limiting membrane hemorrhage (SILMH), intravitreal gas injection for subretinal hemorrhage (SRH) or intraretinal hemorrhage (IRH), and vitrectomy and intravitreal air/gas exchange for multilevel hemorrhage (at least 2 among SILMH/SRH/IRH). RESULTS Complete displacement or resolution of the macular hemorrhage was achieved in all 27 eyes: 7 with SILMH, 7 with SRH, 3 with IRH, and 10 with multilevel hemorrhage. Compared with the baseline score, the 3-month postoperative Early Treatment Diabetic Retinopathy Study score (mean ± SD) improved significantly in SILMH (+42.9 ± 6.9 letters; P < .0001, paired t test), multilevel hemorrhage (+23.9 ± 14.4 letters; P = .0005), and SRH (+17.7 ± 18.4 letters; P = .0440), but not in IRH (+6.7 ± 9.0 letters; P = .3228). Compared with the baseline thickness, the 3-month postoperative central retinal thickness decreased significantly in multilevel hemorrhage (-930.3 ± 290.8 µm; P < .0001), SILMH (-628.4 ± 177.0 µm; P < .0001), IRH (-508.3 ± 72.1 µm; P = .0066), and SRH (-476.9 ± 300.0 µm; P = .0056). The central ellipsoid zone was detectable in 7/7 eyes with SILMH but in none of the eyes in the other 3 groups (P < .0001). No retinal detachment or macular hole occurred in any eyes. CONCLUSION For macular hemorrhage secondary to RAM, anatomic site-oriented therapy using different treatments targeting the hemorrhagic retinal layers is useful. The optimal treatments for individual hemorrhagic retinal layers require further studies.
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Savastano MC, Savastano A, Rizzo S. Pharmacological Adjuncts to Vitrectomy Surgery. Curr Pharm Des 2019; 24:4843-4852. [PMID: 30706802 DOI: 10.2174/1381612825666190130125136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/24/2019] [Indexed: 11/22/2022]
Abstract
Pharmacological adjuncts to vitrectomy surgery are useful tools to better deal with surgery. Their introduction has enriched the therapeutic choice before, during and after operations. Although several classifications could be made to frame adjuncts to vitrectomy, we preferred to divide the pharmacological adjuncts to vitrectomy surgery for therapeutic use in the pre-operatory procedure (neo-adjuvant), for intraoperative use and for post-operatory practice (adjuvant). This type of classification allowed us to explore all the adjuncts based on the timing of their use. The actual interest in vitrectomy surgery is giving rise to considerable interest in new molecules with and without the pharmacological effect that will soon be available for the aid of vitreoretinal surgery.
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Kimura M, Yasukawa T, Shibata Y, Kato A, Hirano Y, Uemura A, Yoshida M, Ogura Y. Flattening of retinal pigment epithelial detachments after pneumatic displacement of submacular hemorrhages secondary to age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 2018; 256:1823-1829. [PMID: 29961921 DOI: 10.1007/s00417-018-4059-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/22/2018] [Accepted: 06/25/2018] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Pneumatic displacement of submacular hemorrhages (SMHs) with intravitreal injection of sulfur hexafluoride (SF6) gas with or without tissue plasminogen activator (tPA) and prone posturing is an effective minimally invasive treatment. We observed some cases in which simultaneous flattening of hemorrhagic pigment epithelial detachments (PEDs) occurred after prone posturing. This study evaluated the impact of pneumatic displacement using tPA to treat PEDs and visual outcomes in eyes with SMHs secondary to neovascular age-related macular degeneration (AMD). METHODS This retrospective analysis reviewed the medical records of 32 patients (33 eyes) who underwent pneumatic displacement for AMD-associated SMHs. The SMHs were related to polypoidal choroidal vasculopathy (PCV) in 24 eyes and typical AMD in nine eyes and treated with intravitreal injection of SF6 gas with tPA. We assessed the postoperative best-corrected visual acuities (BCVAs), prevalence and flattening rates of the PEDs, and the number of additional treatments. RESULTS The mean follow-up period was 35.4 ± 19.8 months. The BCVAs improved significantly in eyes with PCV compared with eyes with typical AMD. Thirty-one (93.9%) of 33 eyes had an accompanying PED. The PEDs flattened in 14 (58.3%) of 24 eyes with PCV but in only one (14.3%) of seven eyes with typical AMD (p = 0.04). A mean of one additional treatment was administered during the first year in 15 eyes with flattened PEDs, which was significantly (p < 0.05) fewer than the 3.6 additional treatments in 16 eyes with persistent PEDs. CONCLUSIONS PEDs often accompany SMHs secondary to neovascular AMD. Pneumatic displacement of the SMHs using tPA unexpectedly flattened the PEDs, especially in eyes with PCV, and was associated with fewer additional treatments.
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Affiliation(s)
- Masayo Kimura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Tsutomu Yasukawa
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan.
| | - Yu Shibata
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Aki Kato
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Yoshio Hirano
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Akiyoshi Uemura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Munenori Yoshida
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
| | - Yuichiro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, Aichi, 467-8601, Japan
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Shortest Distance From Fovea to Subfoveal Hemorrhage Border Is Important in Patients With Neovascular Age-related Macular Degeneration. Am J Ophthalmol 2018; 189:86-95. [PMID: 29499174 PMCID: PMC10020831 DOI: 10.1016/j.ajo.2018.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE To identify factors influencing visual outcome in patients with neovascular age-related macular degeneration (NVAMD) and subfoveal hemorrhage (SFH) treated with anti-vascular endothelial growth factor (VEGF) agents. DESIGN Retrospective case series. METHODS Anti-VEGF-treated eyes with SFH > 1 disc area (DA) were identified (n = 16) and changes in visual acuity (VA) and central subfield thickness (CST) from baseline to last follow-up, along with SFH area, thickness, minimum distance from fovea to SFH border, and time to resolution, were determined. RESULTS At baseline, mean (± standard error of the mean) size and thickness of SFH were 14.9 ± 2.8 DA and 386.6 ± 46.9 μm, and mean Snellen VA and CST were 20/250 and 591.7 ± 57.0 μm. Median follow-up was 47.6 months. While more than 50% of patients had VA ≤ 20/200 at baseline and all time points through week 48, the percentage of patients with VA ≥ 20/50 increased to 30%-40% at months 6 and 12 and remained stable through month 48. Spearman rank correlation demonstrated 2 independent variables that correlated with good visual outcome, smaller area of SFH at baseline (r = -0.630; P = .009), and high frequency of anti-VEGF injections (r = 0.646; P = .007). In exceptional patients with good visual outcome despite large baseline SFH, shortest distance between the fovea and hemorrhage border significantly correlated with baseline VA (r = -0.503, P = .047) and final VA (r = -0.575, P = .02). CONCLUSIONS Patients with NVAMD and thick SFH, but short distance between fovea and uninvolved retina, can have good visual outcomes when given frequent anti-VEGF injections.
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Sharma S, Kumar JB, Kim JE, Thordsen J, Dayani P, Ober M, Mahmoud TH. Pneumatic Displacement of Submacular Hemorrhage with Subretinal Air and Tissue Plasminogen Activator. ACTA ACUST UNITED AC 2018; 2:180-186. [DOI: 10.1016/j.oret.2017.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 10/18/2022]
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