Long-Term Visual Outcome and Its Predictive Factors Following Treatment of Acute Submacular Hemorrhage with Intravitreous Injection of Tissue Plasminogen Factor and Gas

Long-term Efficacy of Oral Valganciclovir in Presumed Cytomegalovirus Unilateral Hypertensive Anterior Uveitis

PURPOSE

To describe long-term efficacy and safety of oral valganciclovir in the treatment of presumed cytomegalovirus (CMV) unilateral hypertensive anterior uveitis.

METHODS

Retrospective review of 40 patients (40 eyes).

RESULTS

All patients presented with high intraocular pressure (mean 39.35 ± 7.58 mmHg), associated with signs of mild anterior uveitis. Oral valganciclovir resulted in control of the intraocular pressures and inflammation in 35 eyes. At the dose of ≥450 mg twice daily, no relapses were documented. The follow-up period ranged from 12 to 108 months (24.45 ± 14.56). At the final follow-up, the intraocular pressure was reduced to 14.92 ± 2.43 mmHg (<0.001). Drug-related complications in the form of leukopenia and azoospermia were reported in one patient.

CONCLUSIONS

Oral valganciclovir effectively and safely controls intraocular pressure and inflammation in presumed CMV anterior uveitis. A long-term treatment course seems necessary.

Role of intravitreal brolucizumab with intravitreal rtPA and pneumatic displacement for submacular hemorrhage: A case series

Purpose

To evaluate the role of intravitreal injection (IVI) of brolucizumab along with intravitreal recombinant tissue plasminogen activator (rtPA) and C3F8 gas injection for large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).

Observations

This was a prospective uncontrolled non-randomized case series conducted at a single site. Three patients with fresh SMH (≤4 days) secondary to nAMD underwent triple therapy with IVI brolucizumab + intravitreal rtPA (50 μg in 0.1 mL) + 0.3 mL of 100% C3F8 gas injection. Post-injection, a face-down position was advised for 5 days with periodic follow-up visits. All three patients had complete resolution of SMH at the end of 4 weeks with a notable improvement in the best-corrected visual acuity (BCVA). No optical coherence tomographic (OCT) biomarkers of disease activity were noted at the end of 12 weeks in the first and the third case and 4 weeks in the second case respectively. There were no ocular or systemic side effects reported in any of the cases.

Conclusions and importance

Intravitreal brolucizumab administered along with intravitreal rtPA and C3F8 gas injection was found to be efficacious and safe for the management of large SMH secondary to nAMD. Complete displacement of SMH with excellent structural and functional outcomes can be seen with triple therapy.

An Innovatory Surgical Technique for Submacular Hemorrhage Displacement by Means of a Bioengineering Perspective

The purpose of this case report is to present a new surgical technique for the treatment of large Subretinal Hemorrhage (SRH) secondary to Age-related Macular Degeneration (AMD). Considering the biomechanics of foam evolution theory, bubble coarsening effect, and gas-liquid biphasic absorption, an SRH due to an AMD case was treated with vitrectomy. The treatment was implemented by subretinal injection of air bubbles combined with rtPA followed by air fluid exchange. The air bubbles helped mess up and remove the blood from the macula area, and no complications occurred. Two weeks postoperatively, there was no sign of hemorrhage and the Central Macular Thickness (CMT) was sharply decreased from 443 μm to 317 μm. At the five-month follow-up, the CMT remained at 267 μm and the patient's visual acuity improved from light perception to 20/70 according to the Snellen chart. The combination of injecting multiple air bubbles and submacular rtPA, followed by air fluid exchange, was able to displace more than (90%) of the subretinal blood just two weeks postoperatively. Our technique is a promising alternative surgical approach for the displacement of SMH due to AMD, with a clear visual and anatomical benefit seen in the early follow-up period.

Management of acute submacular hemorrhage using intravitreal injection of tissue plasminogen activator and gas: A case series

The objective of this case series is the evaluation of the efficacy and visual outcomes after displacement of subretinal hemorrhage using intravitreal injection of recombinant tissue plasminogen activator, expansile gas, and in some cases an anti-vascular endothelial growth factor agent. A case series of 28 eyes of 28 patients (16 men and 12 women with age range 67–95 years) suffering from subretinal hemorrhage (duration range 1–15 days) caused by age-related macular degeneration or retinal macroaneurysm is presented. All the patients were treated with intravitreal injection of recombinant tissue plasminogen activator and gas and some of them received an anti-vascular endothelial growth factor agent between January 2013 and December 2016. The outcomes assessed were visual acuity (preoperatively 1 week, and 1 month postoperatively) with respect to duration and dimension of hemorrhage, displacement of hemorrhage, and possible complications of the procedure. Successful displacement of hemorrhage was achieved in 25 patients (89.3%), 18 of 28 patients had significant improvement in visual acuity 1 week after the treatment, and 22 of 28 patients had significant improvement in visual acuity 1 month after the treatment. The mean improvement of all patients with anatomical displacement of the hemorrhage in visual acuity was 0.7 ± 0.5 (LogMAR) in 1 month. Two patients developed vitreous hemorrhage after the procedure and one retinal detachment. Visual outcome a month after therapy displayed week correlation with duration, diameter, and thickness of hemorrhage. The results lead to the conclusion that intravitreal treatment of recombinant tissue plasminogen activator and expansible gas with or without injection of anti-vascular endothelial growth factor agent is effective in improving visual acuity and displacing submacular hemorrhage secondary to age-related macular degeneration and retinal macroaneurysm. The best functional outcomes can be expected in patients regardless of the size and duration of the hemorrhage.

[Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results (French translation of the article)]

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.

Treatment of hematomas in age related macular degeneration by vitrectomy and subretinal injection of r-tPA: Preliminary results

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.

Location of submacular hemorrhage as a predictor of visual outcome after intravitreal ranibizumab for age-related macular degeneration

Purpose

To evaluate the anatomical and functional outcomes in patients with submacular hemorrhage (SMH) due to age-related macular degeneration (AMD) treated with ranibizumab, and to evaluate the potential role of the SMH location in the final outcome after treatment.

Methods

Participants in this study were 12 treatment-naïve patients with SMH due to neovascular AMD who were treated with intravitreal ranibizumab and had at least 12 months’ follow-up. All patients underwent best-corrected visual acuity measurement and optical coherence tomography at baseline and at every visit posttreatment, while fluorescein angiography was done at baseline and at the discretion of the physician thereafter.

Results

Of the patients, 83.4% showed improvement or stabilization in best-corrected visual acuity after treatment at the 12-month follow-up, with a mean number of 7.3±2.9 injections. Patients with SMH surrounding the foveal area in 360° presented worse anatomical and functional outcomes compared to those with SMH adjacent to the fovea.

Conclusion

Intravitreal ranibizumab seems to be safe and effective, either improving or stabilizing visual acuity, in patients with SMH due to wet AMD. The location of the SMH may predict the final outcome after treatment.

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

Purpose:

The purpose of this study was to evaluate the treatment efficacy of vitrectomy combined with subretinal recombinant tissue plasminogen activator (r-tPA) and factors affecting visual improvement in patients with submacular hemorrhage (SMH) due to neovascular age-related macular degeneration (nAMD).

Materials and Methods:

Medical records of 17 consecutive patients diagnosed with SMH secondary to nAMD were retrospectively reviewed. The initial surgical procedure involved a 23-gauge transconjunctival vitrectomy, subretinal r-tPA application through a self-sealing inferior retinotomy, and sulfur hexafluoride gas for tamponade in all patients. The duration, size, and thickness of the hemorrhage and the pre- and post-operative visual acuity (VA) using a Snellen chart were recorded. VA was converted to logMAR for statistical analysis.

Results:

The average duration and size of the SMH were 12.8 ± 18.2 days and 8.6 ± 5.3 disc areas, respectively. The mean follow-up time was 16.9 ± 4.7 months. A statistically significant visual improvement was found when comparing initial VA with postoperative best-corrected VA (BCVA) and final BCVA (Wilcoxon rank test, P ≤ 0.01). There was no significant correlation between the size of the hemorrhage and postoperative BCVA and final BCVA (Spearman's rho test). There was no statistically significant correlation between the initial VA and postoperative BCVA and final BCVA (Spearman's rho test). There was no significant correlation between the duration of hemorrhage and postoperative BCVA and final BCVA (Spearman's rho test). The preoperative thickness of hemorrhage (747.5 ± 30 μm) was not correlated with postoperative BCVA or final BCVA (Pearson's test).

Conclusions:

Vitrectomy combined with subretinal r-tPA injection and gas tamponade is an effective surgical intervention to preserve VA in selected patients with apparent SMH.

TISSUE PLASMINOGEN ACTIVATOR FOR SUBFOVEAL HEMORRHAGE DUE TO AGE-RELATED MACULAR DEGENERATION: Comparison of 3 Treatment Modalities

PURPOSE

To analyze and compare the effects of three common treatment modalities for a thick subfoveal hemorrhage due to exudative age-related macular degeneration on final visual acuity and the size of the final subretinal scar.

DESIGN

Retrospective case series.

SETTING

Single-site, tertiary referral center.

PATIENTS

Thirty-nine patients with exudative age-related macular degeneration and acute SMH greater than 250 μm.

INTERVENTION

Patients received vitrectomy with a subretinal tissue plasminogen activator (tPA) injection, pneumatic displacement (PD) with intravitreal tPA, or PD without tPA within 2 weeks of presentation.

MAIN OUTCOME MEASURE

Functional outcome was determined by Snellen visual acuity. Anatomical outcome was determined as the final disciform scar size.

RESULTS

Treatment groups did not differ in age, sex, initial visual acuity, the initial area of the thick subfoveal hemorrhage, follow-up duration, lens status, duration of exudative age-related macular degeneration, previous intravitreal bevacizumab injections, or time from last given injection to the acute thick subfoveal hemorrhage. Final visual acuity improved significantly in both the vitrectomy and subretinal tPA injection group (P < 0.001), and the intravitreal tPA injection group (P = 0.002) but not with PD alone. Patients treated with subretinal tPA achieved 40% ± 54% reduction in final scar area, in contrast to 27% ± 35% decrease in patients treated with intravitreal tPA (P = 0.001).

CONCLUSION

Treatment with tPA improves the functional and anatomical outcomes in patients with thick subfoveal hemorrhage due to subfoveal choroidal neovascular membrane secondary to exudative age-related macular degeneration and was superior to PD without tPA. Vitrectomy with subretinal tPA injection reduced the final disciform scar compared with PD with or without intravitreal tPA.

Pneumatic displacement with perfluoropropane gas and intravitreal tissue plasminogen activator for subretinal subfoveal hemorrhage after focal laser photocoagulation in central serous chorioretinopathy

Objective. To report the visual and anatomic outcomes of pneumatic displacement with perfluoropropane (C3F8) gas and intravitreal tissue plasminogen activator (IVTPA) for subretinal subfoveal hemorrhage after focal laser photocoagulation in central serous chorioretinopathy (CSCR). Method. Interventional, retrospective case report of one eye (one patient). Outcome measures included visual acuity (VA), central macular thickness (CMT), and size of the lesion at two weeks of followup. Fluorescein angiography (FA) and optical coherent tomography (OCT) were used to measure anatomic outcomes. Results. A 35-year-old man with history of chronic CSCR received focal laser photocoagulation in the right eye two days before presentation. At initial examination, VA was 20/200 (ETDRS chart), CMT was 398 μ, and a subretinal subfoveal hemorrhage was seen. Tissue plasminogen activator (tPA) at a dose of 25 µg/0.1 mL was injected intravitreally before intravitreal C3F8 injection, and prone positioning was indicated postoperatively. At 24 hours, the hemorrhage had been displaced inferiorly and VA improved to 20/100. Two weeks later, VA improved to 20/80, CMT decreased to 225 μ, and the hemorrhage decreased without foveal involvement. Conclusions. The technique seems safe and effective in treating visually significant subretinal subfoveal hemorrhage.