Efficacy and safety of recombinant tissue plasminogen activator and gas versus bevacizumab and gas for subretinal haemorrhage

Outcomes in the Treatment of Subretinal Macular Hemorrhage Secondary to Age-Related Macular Degeneration: A Systematic Review

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.

One-Year Outcome of Intravitreal Tissue Plasminogen Activator, Ranibizumab, and Gas Injections for Submacular Hemorrhage in Polypoidal Choroidal Vasculopathy

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.

Subretinal Injection of Recombinant Tissue Plasminogen Activator and Gas Tamponade to Displace Acute Submacular Haemorrhages Secondary to Age-Related Macular Degeneration

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.

Subretinal Coapplication of Tissue Plasminogen Activator and Bevacizumab with Concurrent Pneumatic Displacement for Submacular Hemorrhages Secondary to Neovascular Age-Related Macular Degeneration

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.

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.

Different approaches in the management of macular hemorrhage: Case reports and a literature review

Introduction

Macular hemorrhages result in a sudden and profound loss of vision. The primary treatment modalities include observation, intravitreal injection of antiangiogenic drugs, neodymium-doped yttrium aluminum garnet hialoidotomy, intravitreal injection of gas with or without tissue plasminogen activator, as monotherapy or combined with surgery. In this paper, we report four cases of macular hemorrhages of different causes treated with different approaches, and we review the literature in this regard.

Case presentation

All four patients presented different causes of macular hemorrhage. The first case had a preretinal hemorrhage due to a Valsalva retinopathy and was treated with surgery. Case 2 had a multilevel macular hemorrhage due to a rupture of a retinal arteriolar macroaneurysm and was treated with pneumatic displacement, laser, and intravitreal ranibizumab. Case 3 presented an extensive subretinal hemorrhage due to a choroidal rupture after high-energy ocular trauma that was also successfully treated with surgery. The last case was a preretinal hemorrhage due to diabetic retinopathy managed with neodymium-doped yttrium aluminum garnet laser. Different treatment approaches were successfully performed in all cases with good outcomes.

Conclusion

There is an extensive range of options available for the management of macular hemorrhages, and the best option depends on the characteristics of each particular case. Proper and timely management of these diseases can achieve an excellent visual outcome, especially if the location of the hemorrhage is preretinal.

Treatment of macular hemorrhage in retinal arterial microaneurysm: anatomic site-oriented therapy

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.

Sequential tissue plasminogen activator, pneumatic displacement, and anti-VEGF treatment for submacular hemorrhage

PURPOSE

To report the results of our sequential intravitreal (IV) tissue plasminogen activator (tPA), pneumatic displacement (PD), and IV anti-vascular endothelial growth factor (VEGF) treatment in patients with neovascular age-related macular degeneration (nAMD)-related submacular hemorrhage (SMH).

METHODS

A total of 16 eyes of 16 patients with SMH of less than 15 days duration were included in this retrospective pilot study. The tPA was applied on the day of diagnosis, and PD was performed the following day. Patients received 3 consecutive monthly IV injections of ranibizumab starting from 15 days after PD. During the follow-ups, additional ranibizumab treatment was performed if persistent macular or recurrent subretinal or intraretinal fluid hemorrhage was observed.

RESULTS

The mean central retinal thickness was 489 ± 92 μm (311-621 μm) at the time of diagnosis, 324 ± 56 μm (209-409 μm) at the first month, 262 ± 48 μm (197-364 μm) at 3 months, 248 ± 40 μm (190-334 μm) at 6 months, and 253 ± 41 μm (192-356 μm) at the last control (p<0.01). The mean best-corrected visual acuity was 2.08 ± 0.79 logMAR (0.7-3.0 logMAR) at baseline, 1.41 ± 0.70 logMAR (0.56-2.50 logMAR) at the first month, 1.21 ± 0.66 logMAR (0.3-2.0 logMAR) at 3 months, 1.14 ± 0.77 logMAR (0.2-2.50 logMAR) at 6 months, and 1.09 ± 0.73 logMAR (0.3-2.50 logMAR) at the last follow-up (p<0.01).

CONCLUSIONS

Sequential IV tPA, PD, and IV anti-VEGF treatments for SMH in patients with nAMD is effective. However, further studies are needed to establish the best treatment algorithm for SMH in patients with nAMD.

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.

Optical Coherence Tomographic Features and Prognosis of Pneumatic Displacement for Submacular Hemorrhage

PURPOSE

To identify prognostic factors, including optical coherence tomographic features, of visual outcome in exudative age-related macular degeneration with submacular hemorrhage treated with pneumatic displacement.

METHODS

This retrospective interventional case series included 37 eyes with exudative age-related macular degeneration and submacular hemorrhage, all of which underwent pneumatic displacement. The best-corrected visual acuity (BCVA) was measured at diagnosis and at 3 and 6 months after treatment. In addition to demographic and funduscopic parameters, tomographic features such as reflectance of the submacular hemorrhage were analyzed with regard to BCVA at 6 months.

RESULTS

After pneumatic displacement and a subsequent treatment such as laser or anti-vascular endothelial growth factor therapy, the BCVA at 3 and 6 months improved significantly (P < 0.001, respectively). Higher baseline BCVA (P < 0.001), shorter symptom duration (P = 0.007), and younger age (P = 0.014) were significant positive prognostic factors on regression analysis. Among optical coherence tomography characteristics, reflectance of the submacular hemorrhage, the shortest radius of the submacular hemorrhage centered on the fovea, and defects in the ellipsoid zone, and external limiting membrane affected the BCVA at 6 months (P < 0.05).

CONCLUSION

A favorable visual outcome was demonstrated after initial pneumatic displacement and subsequent treatment for submacular hemorrhage. The submacular hemorrhages exhibiting lower reflectance on optical coherence tomography and a smaller shortest radius from the foveal center were found to be good candidates for pneumatic displacement.

Efficacy of Vitrectomy Combined with Subretinal Recombinant Tissue Plasminogen Activator for Subretinal versus Subpigment Epithelial versus Combined Hemorrhages

BACKGROUND

The aim of this study was to compare the outcomes after subretinal recombinant tissue plasminogen activator (rtPA) treatment for subretinal hemorrhages (SRH), subpigment epithelial hemorrhages (SPH), and combined subretinal and subpigment epithelial hemorrhages (CH).

METHODS

An observational analysis of patients treated with subretinal rtPA was performed. The primary endpoint was the assessment of visual improvement (best-corrected visual acuity, BCVA) after surgery. Secondary endpoints were evaluation of the maximal hemorrhage diameter (MHD) and central macular thickness (CMT) measured by spectral domain optical coherence tomography.

RESULTS

From a total of 83 eyes included in the study, 19 eyes showed SRH, 11 eyes SPH, and 53 eyes CH. For SRH and CH, the mean BCVA, MHD, and CMT improved significantly (p < 0.05). For patients with SPH, both the mean MHD and CMT decreased significantly (p < 0.05), whereas the mean BCVA improved only slightly after surgery (p = 0.28).

CONCLUSION

Vitrectomy combined with subretinal rtPA injection and gas or air tamponade has a strong functional and anatomical effect on both SRH and CH and also seems to slightly improve the anatomical outcome in SPH.

Anti-Vascular Endothelial Growth Factor with Gas for Submacular Hemorrhage

PURPOSE

To investigate the treatment outcome of pneumatic displacement and intravitreal anti-vascular endothelial growth factor (VEGF) for submacular hemorrhage (SMH) from exudative age-related macular degeneration (AMD).

METHODS

Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were measured at baseline and at 1, 3, and 6 months after initial treatment in 72 eyes of 72 patients treated with a combination of pneumatic displacement and anti-VEGF injection for SMH from exudative AMD.

RESULTS

Best-corrected visual acuity and CFT showed significant improvement from baseline during the 6-month follow-up period (logarithm of the minimum angle of resolution BCVA from 1.80 to 1.00, CFT from 886 to 383 μm, p < 0.001, respectively). The decrease in subretinal hemorrhage was greater than that in subretinal pigment epithelial hemorrhage at 1 month after initial treatment (p < 0.001). In eyes with symptoms for less than 30 days, higher reflectivity of hemorrhage on optical coherence tomography and higher CFT were associated with lower BCVA after 6 months of treatment (reflectivity B = 0.335, p = 0.007; CFT B = 0.001, p = 0.003).

CONCLUSIONS

The combination of pneumatic displacement and intravitreal anti-VEGF is a useful treatment option for SMH secondary to AMD. Higher baseline CFT and higher reflectivity of hemorrhage were associated with lower BCVA 6 months after initial treatment.

Vitrectomy with subretinal tissue plasminogen activator and ranibizumab for submacular haemorrhages secondary to age-related macular degeneration: retrospective case series of 45 consecutive cases

PurposeTo assess the efficacy of small-gauge vitrectomy with subretinal recombinant tissue plasminogen activator (rtPA) and ranibizumab for submacular haemorrhages secondary to neovascular age-related macular degeneration (nAMD), and to identify the factors associated with visual outcome.MethodsA retrospective case series was performed, including all patients who had small-gauge vitrectomy with subretinal rtPA and ranibizumab for submacular haemorrhages secondary to nAMD. All patients received three consecutive monthly injections of ranibizumab after the surgery, and were reviewed monthly and treated on a pro re nata regime.ResultsA total of 45 eyes of 45 patients were included in the study. Mean age was 77.07±9.67 years, and 32 of 45 patients (71.1%) were women. Surgery was performed on average 6.98±5.70 days after the onset of symptoms, and patients were observed for a follow-up period of 12.9±10.8 months. On average, visual acuity improved -0.59±0.61 LogMAR between presentation and last follow-up. Visual acuity improved in 33 patients (73.3%), remained unchanged in 10 patients (22.2%), and worsened in 2 patients (4.4%). Multiple linear regression showed that patients with smaller haemorrhages (P=0.012) and prompt surgery (P=0.008) had better final visual acuities. A haemorrhage area of ≤30 mm(2) had 91.3% sensitivity and 73.3% specificity for predicting a final visual acuity ≥6/60.ConclusionSmall-gauge vitrectomy with subretinal rtPA and ranibizumab is effective for improving visual acuity in patients with submacular haemorrhages secondary to nAMD. Small haemorrhage area and prompt surgery are associated with better final visual acuity.

Intravitreal Tissue Plasminogen Activator, Ranibizumab, and Gas Injection for Submacular Hemorrhage in Polypoidal Choroidal Vasculopathy

PURPOSE

To investigate the efficacy of intravitreal injection of recombinant tissue plasminogen activator (rt-PA), ranibizumab, and gas without vitrectomy for submacular hemorrhage.

DESIGN

Prospective, interventional, consecutive case series.

PARTICIPANTS

Twenty consecutive patients (20 eyes) with submacular hemorrhage secondary to exudative age-related macular degeneration (AMD) or polypoidal choroidal vasculopathy (PCV).

METHODS

Ranibizumab, rt-PA (25 μg/0.05 ml), and 100% perfluoropropane (0.3 ml) were injected intravitreally, followed by 2-day prone positioning.

MAIN OUTCOME MEASURES

The primary outcome measure was best-corrected visual acuity (BCVA) 6 months after treatment. Secondary outcome measures included central retinal thickness (CRT), central pigment epithelial detachment (PED) thickness, central ellipsoid zone, recurrence rate, and complications.

RESULTS

Underlying disease was exudative AMD in 1 eye and PCV in 19 eyes. Submacular hemorrhage ranged in size from 2 to 31 disc diameters. Complete displacement of submacular hemorrhage was achieved in 17 eyes (85%), and partial displacement was achieved in 3 eyes (15%). Snellen BCVA improved from 20/139 before treatment to 20/65 at 6 months (P = 0.0061). Mean change in Early Treatment Diabetic Retinopathy Study score from baseline was +13 letters (P = 0.0040). Mean CRT decreased from 599 μm before treatment to 208 μm at 6 months (P < 0.0001), and central PED thickness decreased from 188 to 88 μm (P = 0.0140). Three eyes developed vitreous hemorrhage, and 1 eye developed retinal detachment; all were treated surgically, and Snellen BCVA improved at 6 months (P = 0.0012). Recurrence was observed in 10 eyes (50%) within 6 months, but visual acuity was preserved with intravitreal injection of anti-vascular endothelial growth factor (VEGF) pro re nata (PRN). The factors that affect BCVA at 6 months after treatment were pre- and posttreatment central ellipsoid zone (P = 0.0366 and P = 0.0424), pretreatment BCVA (P = 0.0015), and pre- and posttreatment central PED thickness (P = 0.0046, P = 0.0021).

CONCLUSIONS

Subretinal hemorrhage treatment by intravitreal injection of rt-PA, ranibizumab, and gas is useful to achieve hemorrhage displacement and lesion improvement. To preserve visual acuity, early detection of posttreatment recurrence and intravitreal anti-VEGF injection PRN are necessary.

Gas-mediated vitreomacular adhesion release with intravitral ranibizumab injections for exudative age-related macular degeneration

PURPOSE

To evaluate the efficiency of gas-assisted vitreomacular adhesion (VMA) release combined with intravitreal ranibizumab injections for exudative age-related macular degeneration (AMD) patients.

MATERIALS AND METHODS

This prospective, interventional case series included a total of 23 eyes of 22 patients. The eyes were treated with intravitreal injection of 0.3 mL of perfluoropropane (C3F8) gas and concomitant intravitreal ranibizumab injection to stimulate VMA release. After three initial loading injections, additional intravitreal ranibizumab injections were performed pro re nata. Over a 12-month period, monthly examinations were performed for best-corrected visual acuity (BCVA, logMAR; logarithm of the minimum angle resolution), optical coherence tomography, and dilated fundus examinations.

RESULTS

After gas injection, 22 eyes (95.7 %) showed complete VMA release at 1 week. Complete VMA was achieved in all eyes at 2 months after VMA release, without serious ocular adverse events except one patient who developed a retinal tear. Mean BCVA was 0.61 ± 0.37 logMAR (20/81 Snellen equivalents) at baseline and 0.46 ± 0.30 logMAR (20/57 Snellen equivalents) at 12 months (P = 0.135). Mean central macular thickness was 357.9 ± 128.6 μm at baseline and 245.6 ± 60.0 μm at 12 months (P = 0.188). Mean numbers of intravitreal ranibizumab injections were 4.8 ± 2.4 times during 12 months (4 to 8 injections).

CONCLUSION

Gas-assisted VMA release can be used as an efficient alternative for exudative AMD patients with obvious VMA.

Submacular hemorrhage in neovascular age-related macular degeneration: A synthesis of the literature

Large submacular hemorrhage, an uncommon manifestation of neovascular age-related macular degeneration, may also occur with idiopathic polypoidal choroidal vasculopathy. Submacular hemorrhage damages photoreceptors owing to iron toxicity, fibrin meshwork contraction, and reduced nutrient flux, with subsequent macular scarring. Clinical and experimental studies support prompt treatment, as tissue damage can occur within 24 hours. Without treatment the natural history is poor, with a mean final visual acuity (VA) of 20/1600. Reported treatments include retinal pigment epithelial patch, macular translocation, pneumatic displacement, intravitreal or subretinal tissue plasminogen activator, intravitreal anti-vascular endothelial growth factor (VEGF) drugs, and combinations thereof. In the absence of comparative studies, we combined eligible studies to assess the VA change before and after each treatment option. The greatest improvement occurred after combined pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal gas, and anti-vascular endothelial growth factor treatment, with VA improving from 20/1000 to 20/400. The best final VA occurred using combined intravitreal tissue plasminogen activator, gas, and anti-vascular endothelial growth factor therapy, with VA improving from 20/200 to 20/100. Both treatments had an acceptable safety profile, but most studies were small, and larger randomized controlled trials are needed to determine both safety and efficacy.

Anti-vascular endothelial growth factor with or without pneumatic displacement for submacular hemorrhage

PURPOSE

To compare the treatment outcomes of a combination of pneumatic displacement and intravitreal anti-vascular endothelial growth factor, and anti-vascular endothelial growth factor monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Forty eyes treated with a combination therapy and 42 eyes treated with monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration with no significant difference in baseline central foveal thickness were compared. Central foveal thickness and best-corrected visual acuity (BCVA) at baseline, 1, 3, and 6 months after initial treatment were measured and compared between the 2 groups after adjustment of baseline central foveal thickness.

RESULTS

Central foveal thickness (P < .0001) and BCVA (combination, P < .0001; monotherapy, P = .022) were improved after both treatments. Combination therapy showed more rapid improvement of central foveal thickness (P = .009) and BCVA (P = .007) within 1 month than monotherapy, but there was no difference at 6 months (P = .385 and P = .303, respectively). In eyes with subretinal hemorrhage thicker than 450 μm, visual outcome at 6 months was better in the combination therapy group than in the monotherapy group (P = .021), whereas BCVA showed no significant difference between groups in eyes with subretinal hemorrhage less than 450 μm (P = .930).

CONCLUSIONS

Both treatments are useful options for submacular hemorrhage resulting from exudative age-related macular degeneration. Combination therapy may yield a better treatment outcome than monotherapy in eyes with thick subretinal hemorrhage. Nevertheless, the potential for adverse events resulting from pneumatic displacement should be considered.

Submacular hemorrhage in polypoidal choroidal vasculopathy treated by vitrectomy and subretinal tissue plasminogen activator

PURPOSE

To evaluate vitrectomy with subretinal tissue plasminogen activator (t-PA) injection, and air tamponade, followed by intravitreal anti-vascular endothelial growth factor (VEGF) therapy for submacular hemorrhage in polypoidal choroidal vasculopathy (PCV).

DESIGN

Prospective, interventional case series.

METHODS

setting: Two clinics.

PATIENTS

Fifteen eyes of 15 consecutive patients (mean age 72 ± 7 years) with submacular hemorrhage attributable to PCV.

INCLUSION CRITERIA

PCV diagnosis with unorganized submacular hemorrhage greater than 500 μm thick.

EXCLUSION CRITERIA

Submacular hemorrhage attributable to macular diseases (eg, high myopia, typical age-related macular degeneration, retinal angiomatous proliferation, and angioid streaks).

INTERVENTION

Vitrectomy with 4000 IU t-PA injected subretinally and fluid/air exchange. Patients remained facedown for 3 days after surgery. Anti-VEGF drugs were administered as exudative changes required.

MAIN OUTCOME MEASURES

Submacular hemorrhage displacement from the macula and changes in best-corrected visual acuities (BCVAs).

RESULTS

Mean time from onset to surgery was 9.5 ± 4.5 (range, 5-21) days. Mean follow-up period was 9.4 ± 3.1 (range, 6-17) months. Surgery successfully displaced submacular hemorrhages from the macula in all eyes. Mean BCVA at baseline (0.98 ± 0.44) had improved significantly both 1 month after surgery (0.41 ± 0.25, P < .01) and at final visits (0.23 ± 0.25, P < .001). In all eyes, exudative retinal changes relapsed after surgery but were completely resolved by anti-VEGF injections. No complications occurred in any patients.

CONCLUSION

Treating submacular hemorrhage with vitrectomy and subretinal t-PA injection, followed by intravitreal anti-VEGF therapy, is a promising strategy for improving visual acuity in PCV patients warranting further investigation.

Outcomes of eyes with lesions composed of >50% blood in the Comparison of Age-related Macular Degeneration Treatments Trials (CATT)

OBJECTIVE

To compare baseline characteristics, treatment frequency, visual acuity (VA), and morphologic outcomes of eyes with >50% of the lesion composed of blood (B50 group) versus all other eyes (Other group) enrolled in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

DESIGN

Prospective cohort study within a multicenter randomized clinical trial.

PARTICIPANTS

CATT patients with neovascular age-related macular degeneration (AMD).

METHODS

Treatment for the study eye was assigned randomly to either ranibizumab or bevacizumab and to 3 different dosing regimens over a 2-year period. Reading center graders evaluated baseline and follow-up morphology in color fundus photographs, fluorescein angiography (FA), and optical coherence tomography (OCT). Masked examiners tested VA.

MAIN OUTCOME MEASURES

Morphologic features and VA at 1 and 2 years.

RESULTS

The B50 group consisted of 84 of 1185 (7.1%) patients enrolled in CATT. Baseline lesion characteristics differed between groups. In the B50 group, choroidal neovascularization size was smaller (0.73 vs 1.83 disc areas [DA]; P < 0.001), total lesion size was greater (4.55 vs 2.31 DA; P <0.001), total retinal thickness was greater (524 vs 455 μm; P = 0.02), and mean VA was worse (56.0 vs 60.9 letters; P = 0.002). Increases in mean VA were similar in the B50 and Other groups at 1 year (+9.3 vs +7.2 letters; P = 0.22) and at 2 years (9.0 vs 6.1 letters; P = 0.17). Eyes treated PRN received a similar number of injections in the 2 groups (12.2 vs 13.4; P = 0.27). Mean lesion size in the B50 group decreased by 1.2 DA at both 1 and 2 years (primarily owing to resolution of hemorrhage) and increased in the Other group by 0.33 DA at 1 year and 0.91 DA at 2 years (P < 0.001). Leakage on FA and fluid on OCT were similar between groups at 1 and 2 years.

CONCLUSIONS

In CATT, the B50 group had a visual prognosis similar to the Other group. Lesion size decreased markedly through 2 years. Eyes like those enrolled in CATT with neovascular AMD lesions composed of >50% blood can be managed similarly to those with less or no blood.