Subretinal hemorrhage management by pars plana vitrectomy and internal drainage

A new surgical approach for the treatment of a refractory foveal microaneurysm: A case report

Purpose

To report a case of a refractory foveal microaneurysm (MA) that was successfully treated by use of a new surgical procedure.

Observations

This study involved a 79-year-old female with an active foveal MA associated with branch retinal vein occlusion in her left eye. Despite anti-vascular endothelial growth factor treatments, the MA remained active without closure, and best-corrected visual acuity (VA) gradually decreased from 20/20 to 20/200. After our new surgical procedure was explained in detail to the patient, written informed consent was obtained from the patient and the surgery was performed. Briefly, following pars plana vitrectomy, the internal limiting membrane in her left eye was peeled and the retina of the external wall of the MA was then gently incised. The exposed MA was then directly grabbed and pulled up onto the retina using 27-gauge microforceps, and photocoagulation was performed. At 3-months postoperative, closure of the MA and improvement in the retinal findings were observed, and best-corrected VA improved to 20/67.

Conclusions and importance

We report a case of a refractory foveal MA that was successfully treated with a novel surgical technique that closed the MA, avoided thermal damage to the surrounding tissue, and resulted in improved postoperative VA.

Macular Hemorrhage Due to Age-Related Macular Degeneration or Retinal Arterial Macroaneurysm: Predictive Factors of Surgical Outcome

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.

Long-Term Favorable Visual Outcomes in Patients with Large Submacular Hemorrhage

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.

Management of Suture Penetration in Combined Vitrectomy and Scleral Buckle Surgery

Purpose:

To evaluate the surgical outcome of deep or full-thickness suture penetration during combined pars plana vitrectomy and scleral buckle (PPV/SB) surgery.

Methods:

Clinical data of patients who underwent PPV/SB for retinal detachment in our practice between June 2017 and April 2019 were reviewed. Cases with full-thickness scleral penetration were identified. Data including initial presentation, intraoperative complications, and management were collected. Long-term surgical outcome, complications, and recurrent detachment were determined.

Results:

Twenty-three cases with evidence of suture penetration were identified. In none of the cases the penetrated suture was visible in the subretinal space. The suture was replaced in cases with persistent leakage through the penetration site or when the surgical plan involved silicone oil insertion. Subretinal hemorrhage was noted during vitrectomy in 7 (30%) patients. The subretinal hemorrhage migrated to the macula in 2 (9%) cases and was drained through a posterior retinotomy. Retinal incarceration was noted in 4 (17%) cases and was released using a focal retinotomy in 2 (9%)cases to reattach the retina. Late complications included epiretinal membrane in 6 (26%) and recurrent detachment occurred in 2 (9%) patients. Final anatomical success was achieved in all patients.

Conclusions:

We propose new principles in the management of suture penetration during combined PPV/SB surgery. In the absence of a visible penetrated suture, suture replacement is required when there is profuse leakage through the penetration site or if silicone oil is used as tamponade. We recommend removal of submacular hemorrhage through a posterior retinotomy. The incarcerated retina can be flattened using release retinotomies.

Perioperative Management of Anticoagulants in Ocular Surgeries

Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue anticoagulant medications prior to ophthalmic surgeries is nuanced and ultimately based on multiple factors including the type of surgery and the patient’s comorbidities and risk profile. In the setting of cataract surgery, no increased risk of bleeding with anticoagulation was observed in a large prospective study, which suggests that anticoagulation should not be interrupted for the average-risk patient on anticoagulation. In other types of ophthalmic surgery, expert opinion and studies are divided on the perioperative management of anticoagulant therapy. Preoperative thromboembolic risk stratification, intraoperative techniques to minimize bleeding, and postoperative management are also reviewed to generate more comprehensive recommendations on ophthalmic perioperative management of anticoagulation.

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.

Age-Related Macular Degeneration and Vitreous Hemorrhage

Age-related macular degeneration led to vitreous hemorrhage (VH) in six eyes of four patients. Macular involvement was bilateral in three patients and fluorescein angiography performed before VH showed extensive subretinal hemorrhage in the macular region in all eyes. We examine the possible causal mechanisms of VH resulting from age-related macular degeneration. Local risk factors, as outlined in our series by fluorescein angiography, are discussed and systemic risk factors are considered. Three out of the six eyes underwent pars plana vitrectomy for removal of intravitreal blood, and had severe inflammatory reactions in the postoperative period. In the three non-operated eyes spontaneous reabsorption of VH was observed at the end of follow-up.

Surgical Management of Exudative Maculopathies: Preliminary Report

A new surgical approach to the management of exudative maculopathies has been developed including the transvitreal route. As a result of surgery the subretinal spaces are drained and their viscous content removed. A special tool was designed for this operation. The method has been clinically tested on 32 patients (32 eyes) with different forms of age-related macular degeneration in the phase of complicated pigment epithelium detachment and on six patients (six eyes) with myopic exudative maculopathy. The follow-up ranged from 6 to 32 months. No fluid reappeared in the macular zone in patients with age-related macular degeneration, except one; visual function improved in 26 out of 32 cases (81.3%). Similar results were obtained in all six patients with myopic exudative maculopathy.

Surgical management of submacular hemorrhage: experience at an academic Canadian centre

OBJECTIVE

To report the anatomical and visual outcomes of patients with thick submacular hemorrhage (SMH) treated with pars plana vitrectomy (PPV), subretinal tissue plasminogen activator (t-PA), and pneumatic displacement.

DESIGN

Single-centre, retrospective case series.

PARTICIPANTS

A total of 99 eyes of 99 consecutive patients with thick SMH secondary to any underlying etiology treated with PPV with subretinal t-PA and pneumatic displacement by 6 vitreoretinal surgeons at St. Michael's Hospital, Toronto, between July 2004 and August 2016.

METHODS

All medical records and colour fundus photographs were reviewed for data collection. Blood displacement was evaluated at follow-up visits and classified as complete, partial, or none. Main outcome measures included blood displacement at final follow-up, postoperative Snellen best-corrected visual acuities (BCVA), and complication and recurrence rates.

RESULTS

Patients had a mean age of 77.7 ± 12.3 years and were followed up for an average of 18.4 ± 22.3 months. Wet age-related macular degeneration was the most common etiology associated with thick SMH (80.8%). Complete blood displacement was observed by final follow-up in 85.9% of the cases, partial displacement in 12.1%, and none in 2.0%. Mean logMAR BCVA improved from 2.03 ± 0.81 (Snellen 20/2143) at baseline to 1.80 ± 1.00 (Snellen 20/1262; p = 0.009) at final follow-up, and baseline BCVA was a significant predictor of final BCVA (p < 0.001). Early postoperative complications included vitreous hemorrhage in 13 eyes and rhegmatogenous retinal detachment in 8. Recurrent SMH was observed in 12 cases.

CONCLUSIONS

Vitrectomy with subretinal t-PA and pneumatic displacement seems to be an effective treatment for SMH in terms of blood displacement and visual outcomes.

VITRECTOMY WITH SUBRETINAL TISSUE PLASMINOGEN ACTIVATOR AND GAS TAMPONADE FOR SUBFOVEAL HEMORRHAGE: Prognostic Factors and Clinical Outcomes

PURPOSE

To study the prognostic factors and clinical outcomes of patients who underwent pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and gas tamponade for the treatment of subfoveal hemorrhage (SFH).

METHODS

A retrospective noncomparative interventional case series.

RESULTS

Seventy-eight eyes from 77 patients were included. A total of 84.6% of eyes developed SFH from age-related macular degeneration. Partial or complete displacement of the SFH was achieved in 91.5% of eyes within 2 months of surgery. Visual acuity improved from 20/1,449 preoperatively to 20/390 after a mean follow-up time of 6.3 months, corresponding to approximately 5 lines of Snellen acuity improvement (P < 0.001). Better visual acuity was associated with the absence of age-related macular degeneration (P = 0.02) and less hemorrhage superior to the fovea (P < 0.001). Final visual acuity was not associated with the area of SFH (P = 0.17), use of anticoagulants (P = 0.14), or visibility of the ellipsoid layer by optical coherence tomography (P = 0.64). Nine patients (11.5%) developed a recurrence of SFH within the follow-up period. Recurrence of SFH was not associated with concurrent anticoagulant therapy (P = 0.52).

CONCLUSION

An etiology other than age-related macular degeneration with less hemorrhage superior to the fovea predicts a better outcome in patients with SFH treated with pars plana vitrectomy, subretinal tissue plasminogen activator, and gas tamponade.

Management of thick submacular hemorrhage with subretinal tissue plasminogen activator and pneumatic displacement for age-related macular degeneration

PURPOSE

To evaluate the outcome of pars plana vitrectomy, subretinal tissue plasminogen activator (t-PA) infusion and intraocular gas tamponade with and without postsurgical antivascular endothelial growth factor (VEGF) injection for thick submacular hemorrhage due to exudative age-related macular degeneration (AMD).

DESIGN

Retrospective, comparative, interventional case series.

METHODS

setting: 2 retina referral centers. The patient population included 101 eyes of 101 patients with neovascular AMD and thick submacular hemorrhage who underwent surgical displacement of the hemorrhage with or without postoperative anti-VEGF injections. Main outcome measures included degree of blood displacement, best and final postoperative visual acuity (VA), and adverse events. Snellen acuity was converted to logMAR for statistical analysis.

RESULTS

All patients were followed for a minimum of 3 months (mean, 15.3 months, range, 3-70 months). In 83 (82%) of 101 eyes, the procedure resulted in complete hemorrhage displacement from the fovea. Mean preoperative VA was 20/2255 (2.05 logMAR). The acuity significantly improved to 20/893 (1.65 logMAR) at month 1 (P < 0.001) at month 1; 20/678 (1.53 logMAR) at month 3 (P < 0.001), and 20/1150 (1.76 logMAR) at month 12 (P = 0.002). Best postoperative visual acuity improved by at least 1 line in 83 (82%) of 101 eyes, and 19.6% of eyes gained 3 lines or more at month 3. The visual acuity of the group of eyes that received postoperative anti-VEGF injection (n = 39) showed greater visual acuity improvement 6 months postoperatively compared to the group of eyes that did not receive postoperative anti-VEGF. Postoperative complications included vitreous hemorrhage in 2 eyes, rhegmatogenous retinal detachment in 4 eyes, and recurrent thick subretinal hemorrhage in 6 eyes.

CONCLUSIONS

Vitrectomy with subretinal t-PA injection and gas tamponade was found to be relatively effective for displacement of thick submacular hemorrhage with a significant improvement in visual acuity. There is a loss of acuity over time; the addition of postoperative anti-VEGF therapy may help maintain the visual acuity gains.

Submacular hemorrhage: a study amongst Indian eyes

Aim:

To evaluate the management outcomes amongst various treatment modalities for submacular hemorrhage (SMH) in Indian subjects.

Settings and Design:

Retrospective, single-center study.

Materials and Methods:

Patients presenting with SMH between 1999 and 2006 were included. Treatment modalities included: vitrectomy with subretinal recombinant tissue plasminogen activator (r-tPA) assisted SMH evacuation (group 1, n = 14); pneumatic displacement with intravitreal r-tPA and gas (group 2, n = 25); and pneumatic displacement with intraocular gas (group 3, n = 7). Favorable anatomical outcome was defined as complete displacement of SMH from fovea and favorable functional outcome was defined as a gain of >2 Snellen lines from the baseline. Kruskal–Wallis, analysis of variance (ANOVA), and Chi-square tests were used to compare the three groups, while Mann–Whitney and independent t-test were used to evaluate the influence of duration and size of SMH on outcomes.

Results:

There was no difference amongst groups in terms of favorable anatomical (P = 0.121) or functional outcomes (P = 0.611). Eyes with median duration of SMH less than 7.5 days had a significantly higher probability of achieving favorable anatomical outcome compared to eyes with SMH >14.5 days (P = 0.042). However, duration of SMH did not influence functional outcome (P = 0.595). Similarly, size of SMH did not affect anatomical (P = 0.578) or functional (P = 0.381) outcome. Median follow-up was 31.5, 6.5, and 2.5 months in the three groups, respectively.

Conclusions:

Co- existing posterior segment conditions and duration of SMH may influence the choice of treatment modality and treatment outcomes. Pneumatic displacement with r-tPA and r-tPA assisted vitrectomy appear to be favorable options for the management of SMH.

Management of submacular hemorrhage secondary to neovascular age-related macular degeneration with anti-vascular endothelial growth factor monotherapy

PURPOSE

To report the visual and anatomic outcomes of anti-vascular endothelial growth factor (VEGF) monotherapy in the management of marked submacular hemorrhage secondary to neovascular age-related macular degeneration (AMD).

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Nineteen eyes of 18 patients with neovascular AMD and fovea involving submacular hemorrhage comprising greater than 50% of the lesion area were treated with anti-VEGF monotherapy. Main outcome measures included mean visual acuity change from baseline, mean central lesion thickness change from baseline, mean number of injections at 6 months, and adverse events. Snellen visual acuity was converted to approximate ETDRS letter score for the purpose of statistical analysis.

RESULTS

The mean change in approximate ETDRS letter score from baseline was +12 letters at 3 months (P = .003), +18 letters at 6 months (P = .001), and +17 letters at 12 months follow-up (P = .02). Seven eyes received ranibizumab, 6 eyes received bevacizumab, and 6 eyes received both at various time points. The mean number of injections at 6 months was 4.7. The mean OCT central lesion thickness decreased from 755 μm to 349 μm at 6 months follow-up (P = .0008).

CONCLUSIONS

Management with anti-VEGF monotherapy may yield visual and anatomic improvements in eyes with marked submacular hemorrhage secondary to neovascular AMD.

Bullous hemorrhagic retinal detachment because of massive subretinal hemorrhage in patients with age-related macular degeneration

PURPOSE

The authors investigated the surgical outcomes of massive subretinal hemorrhage draining via a retinotomy procedure in bullous hemorrhagic retinal detachment (HRD).

METHODS

Clinical records of consecutive patients with age-related macular degeneration who underwent surgery for bullous HRD were reviewed. Outcomes included anatomical success, visual acuity, and postoperative complications.

RESULTS

Seventeen consecutive eyes of 17 patients were included in this series. Of the 17 eyes, 8 eyes had total HRD and 9 eyes had half total inferior HRD including the macula. The mean interval between initial symptom presentation and operation was 22.6 ± 11.7 days. All patients underwent pars plana vitrectomy and internal drainage of the subretinal hemorrhage through a posterior drainage retinotomy. The mean follow-up period was 37.1 months (range, 12-66 months). Finally, successful retinal reattachment was achieved in 15 of the 17 eyes (88.2%), but 2 remained nonprogressive localized inferior retinal detachment because of proliferative vitreoretinopathy. All preoperative visual acuities were hand movements or worse, and 10 eyes (58.8%) achieved a postoperative minimum functional vision of 20/1000 or better.

CONCLUSION

Successful retinal reattachment and achievement of minimum functional vision is possible after PPV and retinotomy with evacuation of a massive subretinal hemorrhage for bullous HRD secondary to age-related macular degeneration.

Treatment for submacular hemorrhage associated with neovascular age-related macular degeneration

Submacular hemorrhage associated with neovascular age-related macular degeneration is a complication known to have potentially devastating effects on visual acuity. Multiple treatment modalities have been suggested including intravitreal anti-vascular endothelial growth factor injections, photodynamic therapy, pneumatic displacement with or without adjuvant intravitreal tissue plasminogen activator, and pars plana vitrectomy with or without adjuvant subretinal tissue plasminogen activator. However, there remains no consensus on optimal treatment, as clinical trials for neovascular age-related macular degeneration have excluded patients with submacular hemorrhage. This manuscript offers guidelines to the management of subretinal hemorrhage based on its size and characteristics, and highlights the need for clinical trials in this area.

Intravitreous injection of bevacizumab, tissue plasminogen activator, and gas in the treatment of submacular hemorrhage in age-related macular degeneration

PURPOSE

To investigate the benefit of adding bevacizumab to intravitreal recombinant tissue plasminogen activator (rTPA) and gas as initial therapy in subretinal hemorrhage and choroidal neovascularization because of age-related macular degeneration.

METHODS

Thirty-eight consecutive patients with recent (1-31 days) subretinal hemorrhage who were treated with intravitreal rTPA and gas (26 patients) or with intravitreal bevacizumab, rTPA, and gas (12 patients) were included in this retrospective analysis. In all patients, a standardized antivascular endothelial growth factor therapy was followed. Testing of best-corrected visual acuity, biomicroscopy, and fundus examination were performed at 4 weeks and 7 months.

RESULTS

The mean pretreatment best-corrected visual acuity in the rTPA/gas group was 0.08 ± 0.09 and 0.12 ± 0.13 in the bevacizumab/rTPA/gas group. After 4 weeks, it was significantly higher in the bevacizumab/rTPA/gas group (0.25 ± 0.26) than in the rTPA/gas (0.08 ± 0.1) group (P < 0.05). Also, after 7 months, best-corrected visual acuity was significantly higher in the bevacizumab/rTPA/gas group (0.07 ± 0.07 vs. 0.24 ± 0.35; P < 0.05). Reading vision could be restored in 0% (rTPA/gas) versus 50% (bevacizumab/rTPA/gas). Stabilization (0 ± 2 lines) or improvement of best-corrected visual acuity was obtained in 62% (rTPA/gas) versus 84% (bevacizumab/rTPA/gas).

CONCLUSION

From our retrospective pilot study, there is a strong indication that the addition of intravitreal bevacizumab is safe and superior to the displacement of submacular hemorrhages alone with rTPA and gas.

[Pars plana vitrectomy, subretinal injection of recombinant tissue plasminogen activator and fluid-gas exchange in the management of massive submacular hemorrhages secondary to age-related macular degeneration]

INTRODUCTION

The natural prognosis of eyes with subretinal hemorrhage resulting from age-related macular degeneration is generally poor. A variety of therapeutic approaches have been developed but no consensus was found. Therefore, we evaluated a technique consisting of pars plana vitrectomy and subretinal rt-PA injection followed by evacuation of the liquid blood using sulfur hexafluoride (SF6).

PATIENTS AND METHODS

This study was a retrospective clinical case series examining 18 eyes of 16 patients with age-related macular degeneration and thick submacular hemorrhage treated with vitrectomy, subretinal injection of rt-PA (0.5mg), and fluid-gas exchange.

RESULTS

The subretinal hemorrhage was displaced in all 18 cases, revealing a choroidal lesion in 17 eyes. A treatable lesion accountable for the bleeding was identified in ten eyes, which all received a secondary treatment (intravitreal injection or photodynamic therapy). After a mean follow-up of 6 months, the final visual acuity improved in ten eyes. Complications consisted of one case of retinal detachment and one case of hyphema.

CONCLUSION

This surgical technique seems useful in displacing thick submacular hemorrhage secondary to age-related macular degeneration, allowing postoperative fluorescein angiography testing and, potentially, subsequent treatments. However, further controlled and multicentric studies will be required to assess its efficacy and safety in the management of this difficult clinical problem.

Surgical management of massive submacular hemorrhage associated with age-related macular degeneration

PURPOSE

To investigate the safety and efficacy of surgical drainage of massive and elevated submacular hemorrhage associated with age-related macular degeneration through circumferential peripheral 180° temporal retinotomy.

METHODS

Prospective interventional case series of first eyes of six consecutive patients with large elevated submacular hemorrhage. The surgical approach consisted of combined cataract surgery, three-port pars plana vitrectomy, induction of retinal detachment, and circumferential peripheral temporal 180° retinotomy. The temporal retina was reflected and the solid blood clot was removed with a vitreous cutter along with the choroidal neovascular complex. Silicone oil was used as an internal temponade in all patients. Complete clinical examination was performed in all cases preoperatively and postoperatively at 1 and 3 months. After removal of silicone oil, the patients were observed for 12 months.

RESULTS

Submacular hemorrhage was completely removed in all cases the next day after the surgery. All patients experienced improvement of central scotoma. Twelve months after silicone oil removal, visual acuity was defined as improvement in 5 eyes (83%) and stable in 1 eye (17%). No recurrence or complications were observed during the period of follow-up.

CONCLUSION

Our surgical approach could be efficacious to remove a large elevated submacular hemorrhage that is not feasible for any other treatment. It may help to improve the central scotoma and results in limited visual improvement in selected patients.

Iatrogenic retinal traumas in ophthalmic surgery

BACKGROUND

To describe the main retinal iatrogenic traumas possibly related to ophthalmic surgery and the precautions to be adopted to avoid them.

METHODS

The article reviews the main peer-reviewed literature concerning retinal injuries caused by surgically related maneuvers. Safety measures alleged to inhibit any possible iatrogenic damage are also evaluated.

RESULTS

Photochemical damage of the retina, retinal complications after strabismus surgery, retinal complications related to local anesthesia for ophthalmic surgery, retinal damage during cataract surgery and retinal damage during vitreoretinal surgery are the most common iatrogenic retinal injuries. Their incidence is related to risk factors peculiar to each condition.

CONCLUSIONS

Ophthalmic surgeons are aware that there are a number of circumstances in which several undesirable retinal iatrogenic injuries might occur, sometimes with serious consequences. This is why surgeons should take every precaution at each surgical step to avoid any possible retinal iatrogenic damage.

Management of subretinal macular haemorrhage by direct administration of tissue plasminogen activator

BACKGROUND/AIMS

Recent studies on the treatment of acute subretinal macular haemorrhage have shown that the volume of the clot and the time to evacuation have strong prognostic factors for visual outcome. A novel technique for surgical evacuation of these lesions involves direct injection of tissue plasminogen activator (t-PA) into the haematoma using pars plana vitrectomy. The aim of this study was to evaluate the clinical outcomes of this recently described procedure.

METHODS

17 consecutive patients with subretinal macular haemorrhages caused by age related macular degeneration were enrolled. Patient demographics, acuities, and fluorescein angiograms were obtained for all evaluations. All patients underwent complete three port pars plana vitrectomy to enable direct cannulation of the subretinal space and injection of 48 mug of t-PA, partial fluid-air exchange, 1 hour face up supine positioning postoperatively, followed by upright positioning overnight.

RESULTS

88% of patients within the study had stabilisation or improvement of visual acuity. Nine patients had total clearing of the macular haemorrhage and eight patients had subtotal clearing. Two patients had recurrence of the haemorrhage after the procedure and one patient underwent repair for retinal detachment. Occult lesions demonstrated similar outcomes to classic or predominately classic lesions. Nine patients required no therapy after the study to treat subfoveal neovascularisation.

CONCLUSIONS

This study represents one of the largest case series to date showing that direct injection of subretinal t-PA with air-fluid exchange only and no intraoperative clot lysis period can have favourable results.

In-patient management and treatment satisfaction after intravitreous plasminogen activator injection

AIMS

To assess patient satisfaction after intravitreous plasminogen activator injections for subretinal hemorrhages secondary to age-related macular degeneration (AMD) and to analyse how it relates to the patients' postoperative visual and functional abilities. Further, to suggest ways to improve in-patient management and thereby treatment satisfaction.

METHODS

A consecutive series of 101 patients with a subretinal hemorrhage of at least one disk diameter were enrolled in this longitudinal prospective study conducted during 2001-2004. After complete preoperative eye examination all patients were treated with intravitreal injection of 25 microg recombinant tissue plasminogen activator (rTPA) and 0.5 ml sulphur hexafluoride gas (SF6), followed by face-down positioning for 1 week. Patient satisfaction was assessed using standardised questionnaires administered postoperatively at 4 and 12 months. Outcome measures were: (1) responses to the patient satisfaction survey, (2) degree of satisfaction with in-patient management, (3) subjective change in the patients' functional status, and (4) visual acuity results.

RESULTS

Whereas the patients' actual functional status deteriorated from a median value of 2.4 at 4 months to 3.4 at 12 months, their recall of their preoperative functional status shifted from a median value of 4.2 to to 2.3, consecutively. Twelve months after treatment, 75% of patients reported an improved visual acuity, however, only 12% reported satisfaction with treatment. 67.4-87% of patients were dissatisfied with various areas of in-patient management.

CONCLUSIONS

Satisfaction with plasminogen activator injection treatment is low even though patients experience an improved visual and functional status at 12 months. This suggests that the current system requires improvement in certain areas such as in-patient management.

Surgical management of age-related macular degeneration

The development of increasingly refined vitreoretinal surgical techniques has resulted in a variety of surgical procedures for age-related macular degeneration (AMD). These have included submacular surgery with removal of choroidal neovascular membranes and subretinal blood, intraoperative lysis of feeder vessels, pneumatic displacement of subretinal blood and macular translocation surgery. The goals of these procedures have been to improve upon the poor natural history of exudative AMD and restore useful central vision. This article reviews the varied approaches, results and complications of the surgical management of AMD.

Surgery for hemorrhagic choroidal neovascular lesions of age-related macular degeneration: ophthalmic findings: SST report no. 13

PURPOSE

To present best-corrected visual acuity (BCVA) findings and other clinical outcomes from eyes of patients enrolled in one of the Submacular Surgery Trials (SST) evaluating surgical removal versus observation of predominantly hemorrhagic subfoveal choroidal neovascularization (CNV) associated with age-related macular degeneration.

DESIGN

Randomized clinical trial (SST Group B Trial).

PARTICIPANTS

Eligible patients had subfoveal choroidal neovascular lesions greater than 3.5 disk areas (8.9 mm2) composed of at least 50% blood (either blood or CNV underlying the center of the foveal avascular zone) and BCVA of 20/100 to light perception in the study eye.

INTERVENTION

Patients were assigned randomly at time of enrollment to observation or surgical removal of blood and any associated CNV.

MAIN OUTCOME MEASURE

A successful outcome was defined a priori as either improvement in visual acuity (VA), no change in VA, or a decline in VA of no more than 1 line (7 letters) from baseline to the 24-month examination based on an intent-to-treat analysis.

RESULTS

Of 336 patients enrolled, 168 were assigned to each treatment arm; treatment arms were balanced by baseline characteristics. Of 1501 expected examinations 3 months through 36 months after baseline, 1370 (91%) were performed. Loss of > or =2 lines (> or =8 letters) of VA occurred in 56% of surgery eyes, versus 59% of observation eyes examined at 24 months. Although severe loss of VA was not the primary outcome of interest, surgery more often prevented such loss: 36% in the observation arm versus 21% in the surgery arm at the 24-month examination (chi2 P = 0.004). Of initially phakic eyes, the cumulative percentage that had undergone cataract surgery by 24 months was 44% in the surgery arm, compared with 6% in the observation arm. Twenty-seven eyes (16%) in the surgical arm, compared with 3 eyes (2%) in the observation arm, had a rhegmatogenous retinal detachment (RD).

CONCLUSIONS

Submacular surgery as performed in the SST Group B Trial did not increase the chance of stable or improved VA (the primary outcome of interest) and was associated with a high risk of rhegmatogenous RD, but did reduce the risk of severe VA loss in comparison with observation. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

Review Article. New treatments in age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of legal blindness in individuals 50 years and older in the developed world. Choroidal neovascularization (CNV) in exudative AMD is responsible for the majority of severe vision loss. Until recently, laser photocoagulation was the only well-established and widely accepted treatment for CNV. However, it is beneficial only for a small subset of patients, has a high rate of CNV persistence and recurrence and results in iatrogenic, collateral damage to the overlying retina. These issues make it difficult to recommend in the case of subfoveal lesions. Consequently, numerous experimental therapeutic interventions are under investigation with the common objective of destroying the CNV but leaving the foveal neurosensory retina intact. Treatment modalities can be grouped into five major categories: photodynamic therapy; radiotherapy; transpupillary thermotherapy; anti-angiogenic and angiostatic agents; and surgical intervention. The present review aims to explain the rationale behind these new treatments, analyse the evidence for their safety and efficacy, determine their stage of development and indicate in which patients they are potentially useful.

Intravitreous tissue plasminogen activator injection and pneumatic displacement in the management of submacular hemorrhage complicating scleral buckling procedures

PURPOSE

To evaluate the efficacy of recombinant tissue plasminogen activator (rTPA) and sulfur hexafluoride (SF6) in displacing submacular hemorrhage in patients who had scleral buckling procedures complicated by the development of submacular hemorrhage. Final visual acuity and complications of the procedures were evaluated.

METHODS

Sequential intravitreal injections of 50 microg rTPA in 0.1 mL and 0.4 cc SF6 were performed in eight patients who showed submacular hemorrhage 1 day after a scleral buckling procedure. The fundus was checked daily for 3 days after the injection of TPA and gas, and then was followed every week for 1 month and then every 2 months. Patients were observed for at least 6 months. Visual acuity and the status of complications were evaluated.

RESULTS

Submacular hemorrhage was totally or partially displaced extramacularly in all patients on the day after rTPA and SF6 injection. Vitreous hemorrhage was present in all patients. The retina was attached in all patients and no recurrent retinal detachment was noted. Visual acuity was improved at 6 months after treatment in all seven of the patients with macula-off retinal detachments compared to the preoperative visual acuity. The last patient who had a macula-sparing retinal detachment had decreased vision (20/25) at 6 months compared to preoperatively.

CONCLUSIONS

Recombinant tissue plasminogen activator and SF6 injection is an easy procedure that is less complicated than and as effective as internal drainage in patients with submacular hemorrhage developing as a complication of scleral buckling procedures.

Planned two-step vitrectomy for extremely large and thick subretinal hematoma

PURPOSE

To describe a new surgical strategy, planned two-step vitrectomy, for a large and thick subretinal hematoma involving 3 or more quadrants of the fundus. SURGICAL METHODS: In a first-step vitrectomy, a retinotomy was made in the posterior pole, after any vitreous hemorrhage had been removed. Following fluid-gas exchange with no laser photocoagulation around the retinotomy, patients took a face-down position for a few days to a week to facilitate subretinal hemorrhage movement to the vitreous cavity and anterior chamber. In a second-step surgery, the hemorrhage in the vitreous cavity and anterior chamber was washed out. The remaining subretinal hemorrhage was aspirated, and the retina was reattached with fluid-gas exchange and laser photocoagulation around the retinotomy.

RESULTS

The planned two-step vitrectomy was performed in 4 consecutive patients with large and thick subretinal hematomas involving 3 or more quadrants seen during a 3-year period. By a face-down position after the first-step vitrectomy, subretinal hemorrhage moved to the vitreous cavity and anterior chamber. The remaining subretinal hemorrhage in a smaller quantity could be easily removed, leading to retinal reattachment in the second-step surgery.

CONCLUSIONS

The planned two-step vitrectomy is a safer and more effective procedure for removing a large quantity of subretinal hemorrhage in a shorter period of surgical time, compared with hemorrhage removal in a single vitrectomy.

Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid-gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration

PURPOSE

To evaluate a new procedure for displacement of large, thick submacular hemorrhage in patients with age-related macular degeneration.

METHODS

Retrospective review of 11 eyes of 11 patients with age-related macular degeneration and thick submacular hemorrhage (defined as causing retinal elevation detectable on stereo fundus photographs) treated with vitrectomy, subretinal injection of tissue plasminogen activator (25 or 50 microg), and fluid-gas exchange with postoperative prone positioning. Outcome measures included displacement of hemorrhage from the fovea, best postoperative visual acuity, and final postoperative visual acuity.

RESULTS

In the 11 affected eyes of 11 patients (seven men and four women; mean age, 76 years), preoperative visual acuity ranged from 20/200 to hand motions. With surgery, subretinal hemorrhage was displaced from the fovea in all 11 cases. Mean postoperative follow-up was 6.5 months (range, 1 to 15 months). Best postoperative visual acuity varied from 20/30 to 5/200, with improvement in nine (82%) cases and no change in two cases. Eight eyes (73%) measured 20/200 or better, with four of these eyes (36%) 20/80 or better. Final postoperative visual acuity ranged from 20/70 to light perception, with improvement in eight (73%) cases, no change in one case, and worsening in two cases. A statistically significant difference was found between preoperative and best postoperative visual acuity (P =.004) but not between preoperative and final visual acuity (P =.16). Hemorrhage recurred in three (27%) eyes, causing severe visual loss in one eye.

CONCLUSIONS

This technique displaces submacular hemorrhage from the fovea and can improve vision in patients with age-related macular degeneration. However, recurrence of hemorrhage occurred in 27% of eyes and caused severe visual loss in one eye. A randomized, prospective clinical trial is necessary to determine the efficacy of this technique in comparison with other proposed treatments.

Combined cataract extraction and submacular blood clot evacuation for globe perforation caused by retrobulbar injection

A 45-year-old woman, originally scheduled for cataract surgery in the left eye, was referred for management of a globe perforation noticed after the retrobulbar injection of an anesthetic solution. There was a moderate degree of vitreous hemorrhage, and initial visual acuity was hand movement. A submacular blood clot of about 4-disc diameter was detected when the vitreous hemorrhage gradually cleared. One week after the incident, combined phacoemulsification, intraocular lens implantation, pars plana vitrectomy, and submacular clot removal using tissue plasminogen activator (tPA) as an adjunct were performed. Recovery was uneventful. At the last follow-up 6 months after surgery, best corrected visual acuity was 20/30.

Scanning and transmission electron microscopic findings during RPE wound healing in vivo

OBJECTIVE

To examine the scanning (SEM) and transmission (TEM) electron microscopic features of an in vivo rabbit model of retinal pigment epithelial (RPE) wound healing.

METHODS

Hydraulic debridement of the RPE was performed in one eye of each of 35 pigmented rabbits using a pars plana vitrectomy approach. Five of the 35 eyes were examined by either SEM or TEM on each of the following postoperative days: 0, 2, 4, 7, 14, 28 and 56.

RESULTS

TEM revealed that hydraulic RPE debridement results in only focal damage to the RPE basement membrane portion of Bruch's membrane and that this damage is repaired by day 7 without ultrastructural sequelae. SEM and TEM disclosed that the RPE cells at the margin of the debrided bed become flattened and enlarged and evolve a cytoskeletal reorganization with altered apical-basal polarity consistent with the development of a migrating phenotype. This is followed by gradual restoration to a more normal stationary RPE phenotype after initial closure (reepithelialization) of the RPE defect on day 7. RPE hyperplasia also occurs and may contribute to this repair process. Tight junctions are re-established among the apical surfaces of monolayered and multilayered RPE cells by day 7, coinciding with the restoration of the blood outer retinal barrier.

CONCLUSION

Hydraulic debridement of the RPE in vivo is a useful investigational model that provides important insight into the pathogenesis of outer retinal disorders and their treatment with such techniques as submacular surgery or RPE transplantation.

Pearls in the management of submacular hematoma

Subretinal hemorrhage (SRH), complicated by choroidal neovascularization such as age-related macular degeneration, often reduces central vision in middle-aged patients. Although the visual results of SRH removal by surgery seem to have improved recently, the efficacy has not yet been confirmed in a prospective, controlled fashion. Therefore, it cannot be stated with certainty that surgery for SRH is more beneficial than the natural course of the disease. However, we believe surgery is beneficial in selected patients. Herein, we describe our technique for the surgical removal of SRH. The development of safer, more effective techniques should further improve patient outcomes.

Risk factors for proliferative vitreoretinopathy

Proliferative vitreoretinopathy (PVR) is one of the major causes of failure in retinal detachment surgery. To prevent PVR, it is necessary to determine factors predisposing its development. In primary PVR, large retinal tears, long duration of retinal detachment, vitreous hemorrhages, aphakia and choroidal detachment were demonstrated as clinical risk factors for PVR. In postoperative PVR, it was revealed that large breaks, pre- and postoperative choroidal detachment, minor intra- or postoperative hemorrhages, signs of uveitis, extensive retinal detachment, vitrectomy, cryopexy, air injection and preoperative PVR were risk factors for PVR by multivariate analysis. Almost all risk factors for PVR are associated with intravitreal dispersion of retinal pigment epithelial (RPE) cells or breakdown of the blood-ocular barrier which are prerequisite to development of PVR.

Pathophysiology and management of subretinal hemorrhage

Subretinal hemorrhage can arise from the retinal and/or choroidal circulation. Significant subretinal hemorrhage occurs in several conditions, but most commonly is associated with age-related macular degeneration, presumed ocular histoplasmosis, high myopia, retinal arterial macroaneurysm, and trauma. Released toxins, outer retinal shear forces, and a diffusion barrier created by subretinal hemorrhage all contribute to photoreceptor damage and visual loss. The use of tissue plasminogen activator and improvements in surgical instrumentation have facilitated surgical drainage and have made it a useful option in the management of selected cases. Mechanisms of subretinal hemorrhage formation, underlying etiologies, diagnostic evaluation, and the histopathology of damage are summarized. Published surgical series are reviewed and surgical advances are summarized. The value of surgically removing subretinal hemorrhages to improve visual outcome remains unestablished, because definitive studies have not been performed. Guidelines for selecting candidates for surgical intervention are proposed.

Fibrinolysis of experimental subretinal haemorrhage without removal using tissue plasminogen activator

AIMS/BACKGROUND

Human recombinant tissue plasminogen activator (rt-PA) fibrinolysis of subretinal haemorrhage with concomitant removal has been shown to reverse the natural history of photoreceptor degeneration in experimental subretinal haemorrhages if evacuated within 7 days. The aim of the study was to determine whether fibrinolysis of subretinal haemorrhage without concomitant removal would offer a simpler approach with similar photoreceptor sparing.

METHODS

A neodymium YAG laser was used to create experimental subretinal haemorrhages beneath the holangiotic retina of the cat. Tissue plasminogen activator (10 micrograms/ml) was injected into 4 day old subretinal haemorrhages to evaluate its effect on altering the natural history of retinal degeneration. Light and electron microscopy were used to study the histopathological effect.

RESULTS

The injection of rt-PA into large 4 day old subretinal haemorrhages without concomitant removal did not alter the natural history of retinal degeneration. In fact, a second focus of retinal degeneration occurred at a gravity dependent inferior site where the subretinal haemorrhages had migrated.

CONCLUSIONS

There was no therapeutic benefit from the injection of rt-PA into subretinal haemorrhages without con-comitant removal in this cat model.

Surgical removal of submacular hemorrhage using tissue plasminogen activator and perfluorocarbon liquid

PURPOSE

To assess the result of surgical removal of submacular hemorrhage by using tissue plasminogen activator and perfluorocarbon liquid.

METHODS

In 22 consecutive patients (22 eyes), subretinal hemorrhage associated with age-related macular degeneration, which involved the fovea and completely obscured the choroidal vascular pattern, was treated by pars plana vitrectomy. The hemorrhages were liquefied with tissue plasminogen activator, squeezed into the vitreous cavity with perfluorocarbon liquid, and then evacuated.

RESULTS

Efficacy of the procedure was judged by the best postoperative corrected visual acuity, which was 20/100 or better in 16 eyes (73%). Submacular hemorrhage recurred in four (18%) eyes, epiretinal membrane formed in three (14%) eyes, and retinal detachment occurred in three (14%) eyes. Best-corrected final visual acuity was improved postoperatively in 18 (82%) of the 22 eyes, unchanged in three (14%) eyes, and decreased in one (5%) eye, final visual acuity was 20/200 or better in 15 eyes (68%) and limited in other eyes by subretinal hemorrhage of greater than 30 days' duration or subfoveal neovascularizations.

CONCLUSIONS

Use of tissue plasminogen activator and perfluorocarbon liquid in surgical removal of submacular hemorrhage may improve the outcome of surgery by reducing surgically induced retinal damage.