Pneumatic displacement with intravitreal tPA injection versus vitrectomy with sub retinal tPA injection in small and medium sub macular hemorrhages- a multicenter comparative study.

PURPOSE: Comparing between the visual outcomes and post operative complications of two surgical treatments for sub macular hemorrhage, pars plana vitrectomy with tissue plasminogen activator (tPA) injection procedure, and pneumatic displacement of submacular hemorrhage with intravitreal tPA injection. METHODS: A retrospective chart review of patients with sub macular hemorrhage (SMH) was performed. Data was collected from 150 patients with sub macular hemorrhage. Patients were followed up from the day of admission and up to a year post surgery. Evaluation included visual acuity, optical coherence tomography (OCT), fundus examination and rates of complications. RESULTS: Pars plana vitrectomy procedure has showed a better visual outcome in small SMH. Comparing complications between the two treatment modalities, no significant difference has been found in the study. CONCLUSIONS: Pars plana vitrectomy and tPA showed a clear advantage with a trend of better visual acuity as well as a significant predictor to better visual acuity for small and medium sub macular hemorrhage.

Displacement of Submacular Hemorrhage Using Subretinal Cocktail Injection versus Pneumatic Displacement: A Real-World Comparative Study.

INTRODUCTION: The objective of this study was to compare the outcome of submacular hemorrhage (SMH) displacement using pneumatic displacement with intravitreal expansile gas versus pars plana vitrectomy (PPV) with subretinal injection of tissue plasminogen activator (tPA), anti-vascular endothelial growth factor (VEGF) agent, and air as primary surgery. METHODS: Retrospective interventional case series of 63 patients who underwent surgical displacement of SMH secondary to neovascular age-related macular degeneration (nAMD) or polypoidal choroidal vasculopathy (PCV) from May 1, 2015, to October 31, 2022. Medical records were reviewed for diagnosis, logMAR visual acuity (VA), central subfield thickness (CST), and postoperative displacement rates and complications up to 12 months after operation. RESULTS: The diagnosis was nAMD in 24 (38.1%) and PCV in 39 (61.9%) eyes. There were 40 (63.5%) eyes in the pneumatic displacement group (38 received C3F8, 2 received SF6) and 23 (36.5%) eyes in the subretinal cocktail injection. Mean baseline VA was 1.46 and 1.62, respectively (p = 0.404). The subretinal injection group had more extensive SMH (p = 0.005), thicker CST (1,006.6 µm vs. 780.2 µm, p = 0.012), and longer interval between symptom and operation (10.65 vs. 5.53 days, p < 0.001). The mean postoperative VA at 6 months was 0.67 and 0.91 (p = 0.180) for pneumatic displacement and subretinal injection groups, respectively, though VA was significantly better in the pneumatic group at 12-month visit (0.64 vs. 1.03, p = 0.040). At least 10 mean change in VA were >10 letters gain in both groups up to 12 months. Postoperative CST reduction was greater (625.1 µm vs. 326.5 µm, p = 0.008) and complete foveal displacement (87.0% vs. 37.5%), p < 0.001, odds ratio [OR] = 11.1) and displacement to arcade or beyond (52.5% vs. 17.5%, p = 0.009, OR = 5.15) were more frequent in the subretinal injection group. Two patients with failed pneumatic displacement were successfully treated with subretinal cocktail injection as a second operation. CONCLUSION: Surgical displacement of SMH leads to clinically meaningful improvement in VA. PPV with subretinal cocktail injection is more effective than pneumatic displacement in displacing SMH with similar safety profile despite longer interval before operation, higher CST, and more extensive SMH at baseline. Retinal surgeons could consider this novel technique in cases with thick and extensive SMH or as a rescue secondary operation in selected cases.

Current Management of Subretinal Hemorrhage in Neovascular Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss among individuals aged 65 years and older in the USA. For individuals diagnosed with AMD, approximately 12% experience varying levels of subretinal hemorrhage (SRH), which can be further classified by size into small, medium, and massive measured in disc diameters. SRH is an acute and rare sight-threatening complication characterized by an accumulation of blood under the retina arising from the choroidal or retinal circulation. Released iron toxins, reduced nutrient supply, fibrin meshwork contraction, and outer retinal shear forces created by SRH contribute to visual loss, macular scarring, and photoreceptor damage. SRH treatment strategies aim to displace hemorrhage from the foveal region and prevent further bleeding. Although there are no standardized treatment protocols for SRH, several surgical and nonsurgical therapeutical approaches may be employed. The most common surgical approaches that have been utilized are pars plana vitrectomy (PPV) combined with multiple maneuvers such as the removal of choroidal neovascularization lesions, macular translocation, retinal pigment epithelium patch repair, SRH drainage, intravitreal injection of recombinant-tissue plasminogen activator (tPA), expansile gas and air displacement, and anti-vascular endothelial growth factor (anti-VEGF) injections. Nonsurgical therapeutical approaches include intravitreal anti-VEGF monotherapy, intravitreal tPA administration without PPV, and photodynamic therapy. This review article aims to explore the current treatment strategies and supporting literature regarding both surgical and nonsurgical, of SRH in patients with AMD. Moreover, this article also aims to highlight the distinct treatment modalities corresponding to different sizes of SRH.

STEP-WISE APPROACH TO THE MANAGEMENT OF SUBMACULAR HEMORRHAGE USING PNEUMATIC DISPLACEMENT AND VITRECTOMY: The Manchester Protocol.

PURPOSE: To evaluate a sequential approach of pneumatic displacement followed by vitrectomy (pars plana vitrectomy) in failed cases to deal with submacular hemorrhage (SMH) of various etiologies. METHODS: Retrospective, nonrandomized interventional case series of consecutive patients with SMH of up to 2 weeks' duration, who were treated with a stepwise approach. Step 1 involved intravitreal injection of 0.3 mL 100% C3F8 and recombinant tissue plasminogen activator 50 µg/0.1 mL. If unsuccessful, a prompt pars plana vitrectomy with subretinal recombinant tissue plasminogen activator 50 µg/0.1 mL and 20% SF6 gas tamponade was performed as a second attempt to displace the SMH. RESULTS: Thirty-one patients with SMH underwent pneumatic displacement; 24 (77.4%) had a successful outcome without further intervention. The mean presenting visual acuity of the "successful cohort" was 1.34 logMAR (20/440 Snellen), improving to 0.83 logMAR (20/135 Snellen) 1 month after treatment. Five of the seven patients with failed pneumatic displacement underwent pars plana vitrectomy with subretinal recombinant tissue plasminogen activator at an average of 5 days poststep 1, with successful SMH displacement in 3 patients, giving an overall success of 87.1% for this treatment protocol. CONCLUSION: A sequential approach of expansile gas injection followed by prompt pars plana vitrectomy, aided by recombinant tissue plasminogen activator at both steps, is a coherent, logical pathway to treat SMH with high anatomical and functional success.

VISUAL PROGNOSIS AFTER PNEUMATIC DISPLACEMENT OF SUBMACULAR HEMORRHAGE ACCORDING TO AGE-RELATED MACULAR DEGENERATION SUBTYPES.

PURPOSE: This study compared the visual outcome after pneumatic displacement of submacular hemorrhage among patients with different subtypes of age-related macular degeneration (AMD). METHODS: We retrospectively reviewed the medical records of 67 patients (67 eyes) who underwent treatment for submacular hemorrhage associated with AMD. All the patients underwent pneumatic displacement. Demographic parameters, visual acuity, and anatomical features were analyzed among AMD subtypes: typical AMD, polypoidal choroidal vasculopathy (PCV), and retinal angiomatous proliferation (RAP). RESULTS: Among the eyes with submacular hemorrhage, 24, 30, and 13 eyes had typical AMD, PCV, and RAP, respectively. Post-treatment best-corrected visual acuity was best in the PCV group and worst in the RAP group (P < 0.001). The proportion of eyes with improved visual acuity was highest in the PCV subtype and lowest in the RAP subtype (P = 0.044). Logistic regression analysis showed that AMD subtype (P = 0.016) and time to treatment (<7 days) (P = 0.037) are associated with the final visual outcome. CONCLUSION: The final post-treatment visual outcome after the incidence of submacular hemorrhage was best in the PCV group and worst in the RAP group. Age-related macular degeneration subtype is a significant factor associated with the visual prognosis of submacular hemorrhage.

Ocular Adverse Effects of Amiodarone: A Systematic Review of Case Reports.

SIGNIFICANCE: Amiodarone is an excellent antiarrhythmic medication; however, it has numerous systemic and ocular adverse effects. PURPOSE: We aimed to improve our understanding of amiodarone and its ocular adverse effects by performing a systematic review and meta-analysis of published case reports. METHODS: This systematic review was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We used the MEDLINE database, primarily through PubMed, and used keywords (amiodarone, eye, eye diseases, visual/ocular adverse effects/manifestations) to identify case reports of ocular adverse effects after amiodarone use. The initial search resulted in 92 total case reports. However, after excluding nonrelevant case reports, 25 cases were selected for the final analysis. RESULTS: Among the patients in the 25 case reports, 18 were male (72%), and the median age was 66 ± 9.9 years. In 15 cases (60%), the patients reported halos around light and/or decrease in vision after amiodarone use. The most common ophthalmic examination findings were cornea verticillata/vortex keratopathy in 19 cases (76%), followed by different patterns of papilledema and retinal hemorrhages in 5 cases (20%). Discontinuation of amiodarone was the most common intervention, followed by application of topical heparin. Outcomes among case reports were variable. CONCLUSIONS: Cornea verticillata/vortex keratopathy was the most common ocular adverse effect in cases where amiodarone was administered. Early recognition of amiodarone-induced ocular adverse effects is imperative to prevent worsening keratopathy or uncommon adverse effects. Collaboration between physicians prescribing amiodarone-to recognize the ocular symptoms-and referral to eye care physicians are important.

Intravitreal Recombinant Tissue Plasminogen Activator and Sulphur Hexafluoride Gas for Submacular Haemorrhage Displacement in Age-Related Macular Degeneration: Looking behind the Blood.

PURPOSE: To evaluate the effectiveness of recombinant tissue plasminogen activator (rtPA) and sulphur hexafluoride gas (SF6) intravitreal injection for the displacement of large submacular haemorrhages (SMH) secondary to neovascular age-related macular degeneration and for guiding the selection of additional treatments or observations for choroidal neovascularization (CNV). METHODS: The medical records of consecutive patients with recent-onset, large SMH, treated at Sacro Cuore Hospital from January 2004 to May 2016, were retrospectively analysed. All eyes underwent a 0.05-mL intravitreal injection of 50 µg rtPA, 0.3 mL of 100% SF6, and then face-down positioning. Afterwards, the eyes received additional treatments for CNV or observation, based on the severity and extent of the underlying pathology. The multimodal imaging features revealed after blood displacement were analysed and then correlated to the treatment selected as a second therapeutic option. RESULTS: A total of 96 eyes met the inclusion criteria and was evaluated in this study. SMH was displaced from the fovea in the majority of the eyes (76%), allowing several diagnostic tools to evaluate the underlying macular features. In 19 cases (19.8%) exhibiting severe macular damage, no additional treatment was applied. In the remaining eyes, subsequent treatments included anti-vascular endothelial growth factor injections (44.8%), photodynamic therapy (n = 2), and submacular surgery (35.4%). Statistically significant correlations were found between the macular findings revealed after blood displacement and the additional treatments or observations selected for the underlying disease. The mean follow-up was 35 months. Improvements in visual acuity were statistically significant up to 3 years. CONCLUSION: Intravitreal rtPA and gas injection was found to be effective for the displacement of large SMH, allowing postoperative diagnostic testing, and thus guiding the opportunity to apply further treatments. The addition of subsequent individualized treatments may allow long-term visual gain in selected cases.

[Treatment of retinopathy of incontinentia pigmenti by anti-vascular endothelial growth factor].

Objective: To investigate the treatment of retinopathy of incontinentia pigmenti by anti-vascular endothelial growth factor. Methods: Retrospective study of 5 patients(8 eyes) diagnosed retinopathy of incontinentia pigmenti from 2005 to 2017, including 0 males and 5 females (8 eyes involved) with an average age of 2.4 months(range, 1-5 months). Medical history and family history were recorded in detail for all children. We did the examination of anterior segment of the eyeball, vitreous body,fundus and intraocular pressure for the 5 patients(8eyes).What's more,wo also took pictures for fundus with the machine of Retcam. Fundus fluorescence angiography (FFA) was performed in 2 patients(4 eyes). Different surgical methods were selected according to the specific conditions of the eye and postoperative were observed. Results: At the time of initial diagnosis, preretinal hemorrhage did not affect the macular region in 3 cases (5 eyes), pre retinal hemorrhage affected the macular region in 1 case(1 eye), the retinal neovascularization in 3 cases(5 eyes), the retinal detachment in 2 cases(2 eyes), and nonvascular zone of peripheral retinal in 5cases(8 eyes). Treatment and drug selection: 3 cases(5 eyes) were treated with injection anti-VEGF drug into vitreous body cavity, 1 case(1 eye) was treated with injection anti-VEGF drug into vitreous body cavity plus laser photocoagulation, 1 case(1 eye) was treated with anti-VEGF drugs plus vitrectomy. 1 case(1 eye) was treated with anti-VEGF drugs plus retinal cryotherapy and sclera bucking. In patients of injection anti-VEGF drug into vitreous body cavity, 2 cases(3 eyes) were given a single dose and 1 case (2 eyes) was given a repeated dose. Drug selection: 4 cases(6 eyes) ranibizumab injection (injection dose 0.025 ml), 1 case (2 eyes)conbercept injection (injection dose 0.025 ml). To follow-up date, etina was flat in 4 patients (7 eyes), epiretinal membrane in 2 patients(2 eyes), retinal detachment in 1 patient(1 eye). Conclusions: The efficacy of anti-vascular endothelial growth factor in the treatment of retinopathy of incontinentia pigmenti was prelininarily confimed.However,the optimal use timing,dosage,local and systemic safety issues were needed to be further studied. (Chin J Ophthalmol, 2019, 55:294-301).

Flattening of retinal pigment epithelial detachments after pneumatic displacement of submacular hemorrhages secondary to age-related macular degeneration.

PURPOSE: Pneumatic displacement of submacular hemorrhages (SMHs) with intravitreal injection of sulfur hexafluoride (SF6) gas with or without tissue plasminogen activator (tPA) and prone posturing is an effective minimally invasive treatment. We observed some cases in which simultaneous flattening of hemorrhagic pigment epithelial detachments (PEDs) occurred after prone posturing. This study evaluated the impact of pneumatic displacement using tPA to treat PEDs and visual outcomes in eyes with SMHs secondary to neovascular age-related macular degeneration (AMD). METHODS: This retrospective analysis reviewed the medical records of 32 patients (33 eyes) who underwent pneumatic displacement for AMD-associated SMHs. The SMHs were related to polypoidal choroidal vasculopathy (PCV) in 24 eyes and typical AMD in nine eyes and treated with intravitreal injection of SF6 gas with tPA. We assessed the postoperative best-corrected visual acuities (BCVAs), prevalence and flattening rates of the PEDs, and the number of additional treatments. RESULTS: The mean follow-up period was 35.4 ± 19.8 months. The BCVAs improved significantly in eyes with PCV compared with eyes with typical AMD. Thirty-one (93.9%) of 33 eyes had an accompanying PED. The PEDs flattened in 14 (58.3%) of 24 eyes with PCV but in only one (14.3%) of seven eyes with typical AMD (p = 0.04). A mean of one additional treatment was administered during the first year in 15 eyes with flattened PEDs, which was significantly (p < 0.05) fewer than the 3.6 additional treatments in 16 eyes with persistent PEDs. CONCLUSIONS: PEDs often accompany SMHs secondary to neovascular AMD. Pneumatic displacement of the SMHs using tPA unexpectedly flattened the PEDs, especially in eyes with PCV, and was associated with fewer additional treatments.

Long-term visual outcomes for treatment of submacular haemorrhage secondary to polypoidal choroidal vasculopathy.

IMPORTANCE: There is no consensus on the optimal management of submacular haemorrhage (SMH) secondary to polypoidal choroidal vasculopathy (PCV). BACKGROUND: To compare the long-term outcome of three treatment strategies for PCV with SMH. DESIGN: Retrospective case series at two tertiary hospitals. SAMPLES: A total of 48 consecutive eyes treated between July 2006 and March 2016. METHODS: Patients were grouped according to the treatment received: 22 eyes with intravitreal bevacizumab (IVB), 14 with a combination of IVB and pneumatic displacement (PD) and 12 with IVB and vitrectomy (TPPV). MAIN OUTCOME MEASURES: Change in best-corrected visual acuity (BCVA) at onset and up to 24 months. Secondary measures included demographic data, imaging data and complications. RESULTS: Comparing the mean BCVAs of the groups revealed significant differences only at month 1 (P = 0.005). Changes in the mean BCVA over time revealed no significance in the resulting final BCVA (P = 0.062), which was 20 out of 155 (logMAR 0.89 ± 0.64) for IVB monotherapy, 20 out of 174 (0.94 ± 1.04) for combined IVB + PD, and 20 out of 195 (0.99 ± 0.90) for combined IVB + TPPV eyes. Sustained long-term improvement of over three Snellen lines was found in seven (31.82%) IVB monotherapy, 10 (71.43%) combined IVB + PD, and seven (58.33%) combined IVB + TPPV eyes (P = 0.043). SMH recurrence was observed in two eyes after IVB monotherapy and one eye after combined IVB + PD (P = 0.786). CONCLUSIONS AND RELEVANCE: IVB monotherapy appears to be as effective as combination therapies for treating SMH secondary to PCV with regards to BCVA at 24 months, and may be a cost-effective strategy for long-term management.

The role of pigment epithelial detachment in AMD with submacular hemorrhage treated with vitrectomy and subretinal co-application of rtPA and anti-VEGF.

PURPOSE: To assess the incidence of pigment epithelial detachment (PED) in age-related macular degeneration (AMD) with submacular hemorrhage (SMH) and its response to treatment with pars plana vitrectomy (ppV), subretinal co-application of recombinant tissue plasminogen activator (rtPA) and anti-VEGF, and an intravitreal gas tamponade. METHODS: Consecutive interventional case series of 132 eyes of 129 patients with neovascular AMD with SMH. All eyes underwent ppV with subretinal co-application of rtPA and bevacizumab followed by a gas tamponade. Postoperatively, two additional intravitreal anti-VEGF injections were applied monthly, followed by intravitreal anti-VEGF injections applied PRN thereafter. PEDs and SMHs were evaluated with SD-OCT pre- and postoperatively. RESULTS: Preoperatively, 88 of 132 (67%) eyes were examined by OCT, and in 81 of these eyes the RPE could be visualised. A PED was found in 74 (91%) eyes, and no PED was found in five (6%) eyes. Median height of preoperative PED was 503 µm (range 150-1242, n = 65) and reduced to 344 (n = 62) and 306 µm (n = 27) after 3 and 12 months respectively. Two eyes showed a pre-existing rip of the RPE. Postoperatively, a rip was documented in 12 of 128 (9%) eyes. Median height of SMH was 762 µm (range 217-1840), median diameter was 4.3 (1.5-15) disc diameter. A complete displacement of the SMH from the fovea was achieved in 112 of 129 (87%) eyes. Overall, median best-corrected logMAR visual acuity (BCVA) improved significantly from preoperative 1.6 (0.5-2.0, n = 132) to 1.0 (0.2-2.0) 3 (n = 132) and 12 months (n = 74) postoperatively. Excluding eyes with pre-existing macular scars (n = 22), BCVA 3 months postoperatively was 0.8. Height of PED or SMH did not correlate with postoperatively BCVA, while size of SMH showed a mild correlation (rho = 0.25, p = 0.005). CONCLUSION: PpV with subretinal co-application of rtPA and bevacizumab and an intravitreal gas tamponade effectively displaces SMH and improves BCVA. Preoperatively, PED is found in the majority of eyes. Height of PED or SMH did not correlate with postoperatively BCVA. Tears of the RPE occur as frequently as in exudative AMD without SMH.

The effects of a treatment combination of anti-VEGF injections, laser coagulation and cryotherapy on patients with type 3 Coat's disease.

BACKGROUND: To examined the curative effect of vitreous injection with ranibizumab,laser coagulation and cryotherapy in treating stage 3 Coats' disease with exudative retinal detachment. METHODS: Seventeen patients with stage 3 Coats' disease were enrolled in the study. All eyes were treated with vitreous injection of ranibizumab as initial treatment, and subsequent treatment depended on the absorption of subretinal fluid, Including cryotherapy and laser photocoagulation. Repeat treatment for the two treatment intervals occurred in ≥1 month. The mean follow-up time was 24.12 ± 5.99 months. The main data evaluation and outcome measurements included the patient's vision, intraocular pressure(IOP), optical coherence tomography (OCT), slit lamp examination, indirect ophthalmoscopy, color Doppler imaging (CDI) and color fundus image analysis. The following variables were compared between groups: abnormal vascular changes, subretinal fluid and exudate absorption, retinal reattachment and complications. The final follow-up results were used to determine the effectiveness of treatment. RESULTS: Of the 17 patients included, 88.24% were male and 11.76% were female. Visual acuity was less than 0.02 in 12 eyes before surgery and 8 eyes after surgery. Visual acuity improved in 7 eyes, accounting for 41.18% of cases, and remained unchanged in 7 eyes, accounting for 41.18% of cases. Three patients were too young to undergo the operation, accounting for 17.65% of cases. The best vision was 0.1. Patients were treated 1 to 5 times for an average of 2.82 ± 0.95 times each. There was no statistically significant difference (t = 1.580, p = 0.135) between the preoperative and postoperative intraocular pressures. However, there was a statistically significant difference between the preoperative and postoperative retinal detachment height (2- related samples Wilcoxon signed rank test with z = 3.517, p = 0.000). The results further showed that all patients had different degrees of subretinal fluid absorption, and some of the new blood vessels subsided. All patients were successfully treated with laser and cryosurgery. No ocular or systemic complications were observed during follow-up. CONCLUSIONS: Intravitreal ranibizumab (IVR), laser coagulation and cryotherapy were effective in the treatment of Coats' disease with exudative retinal detachment. TRIAL REGISTRATION NUMBER: We retrospectively registered our study, The trial registration number (TRN) is ChiCTR-ONC-17011161 and date of registration is April 16, 2017.

Efficacy of Vitrectomy Combined with Subretinal rtPA Injection with Gas or Air Tamponade.

Background Functional and anatomical outcome after vitrectomy with rtPA combined with gas or air tamponade. Patients and methods Retrospective analysis of pseudophakic patients treated with subretinal rtPA and gas or air tamponade. The primary endpoint was displacement of haemorrhage six months after surgery. The secondary endpoints were visual acuity (BCVA), haemorrhage diameter (MHD) and central macular thickness (CMT), as measured by SD-OCT. Results 53 of 85 eyes were pseudophakic. 27 of these eyes were treated with air tamponade and 26 with gas tamponade. For patients with air tamponade, the mean BCVA improved from 20/530 to 20/355 (p = 0.01). MHD and CMT decreased from 6386 ± 2281 µm to 3805 ± 2397 µm (p < 0.001) and 895 ± 592 µm to 532 ± 386 µm (p < 0.001), respectively. For patients with gas tamponade, the mean BCVA improved only slightly, from 20/471 to 20/394 (p = 0.17). MHD and CMT exhibited statistically significant decreases from 6759 ± 1773 µm to 3525 ± 1548 µm (p < 0.001) and 1089 ± 587 µm to 537 ± 251 µm (p < 0.001), respectively. Conclusions Vitrectomy with subretinal rtPA injection has strong functional and anatomical effects on submacular haemorrhages with both gas and air tamponade.

Peripheral choroidal neovascular membrane in a case of peripheral exudative hemorrhagic chorioretinopathy managed with combination therapy.

To report a case of peripheral exudative hemorrhagic chorioretinopathy (PEHCR) associated with extramacular choroidal neovascular membrane (CNVM). A 65-year-old female with BCVA of 3/60 in the RE was diagnosed to have PEHCR with peripheral CNVM. She had subretinal fluid in the macular region. The patient was treated successfully with a single dose of intravitreal bevacizumab followed by laser photocoagulation of the CNVM. BCVA was 6/24 after 3 months and subretinal fluid had resolved. PEHCR may be associated with extramacular CNVM and hence may cause visual loss. Such extramacular CNVMs respond well to combination therapy which offers a permanent cure.

INTRAVITREAL VERSUS SUBRETINAL ADMINISTRATION OF RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR COMBINED WITH GAS FOR ACUTE SUBMACULAR HEMORRHAGES DUE TO AGE-RELATED MACULAR DEGENERATION: An Exploratory Prospective Study.

PURPOSE: Current management of submacular hemorrhage (SMH) favors vitrectomy and gas with subretinal administration of recombinant tissue plasminogen activator (rtPA) over mere intravitreal rtPA injections and gas. In this study, we aimed to compare the effectiveness of both treatment modalities to displace submacular blood. METHODS: Twenty-four patients with SMH secondary to age-related macular degeneration were included. The SMH had to exist ≤14 days at time of surgery and SMH thickness had to be between 250 µm and 1,250 µm. Patients were randomized to either intravitreal injections of rtPA, perfluoropropane (C3F8) gas, and bevacizumab (n = 12) or vitrectomy with subretinal rtPA administration, intravitreal C3F8 gas, and bevacizumab (n = 12). The SMH volume change was measured on spectral domain optical coherence tomography postoperatively within a 2.5-mm cylinder centered at the fovea. RESULTS: Median relative volume reduction of subretinal blood at 6 weeks postoperatively was 97% (95% confidence interval: 91-99%) in the intravitreal rtPA group and 100% (95-100%) in the subretinal rtPA group and did not differ significantly between groups (P = 0.56). CONCLUSION: Both treatment modalities effectively displaced SMH in this exploratory clinical trial. To more definitely study the noninferiority of intravitreal rtPA with gas to subretinal rtPA, vitrectomy with gas, a larger clinical trial would be necessary.

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.

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.

Postoperative Hemorrhagic Occlusive Retinal Vasculitis: Expanding the Clinical Spectrum and Possible Association with Vancomycin.

PURPOSE: To describe a syndrome of hemorrhagic occlusive retinal vasculitis (HORV) that developed after seemingly uncomplicated cataract surgery. DESIGN: Retrospective case series. SUBJECTS: Eleven eyes of 6 patients from 6 different institutions. METHODS: Cases were identified after discussion among retina specialists. The findings on presentation, clinical course, and outcome of a series of 7 eyes of 4 patients were compared with a previous report of 4 eyes of 2 patients, and data from both series were combined for a comprehensive analysis. MAIN OUTCOME MEASURES: Historical data, examination findings, imaging results, systemic evaluation findings, treatment regimens, and visual outcomes. RESULTS: Eleven eyes of 6 patients underwent otherwise uncomplicated cataract surgery, receiving viscoelastic and prophylactic intracameral vancomycin during the procedure. Despite good initial vision on postoperative day 1, between 1 to 14 days after surgery, all eyes demonstrated painless vision loss resulting from HORV. Extensive ocular and systemic evaluations were unrevealing in all patients. All patients were treated with aggressive systemic and topical corticosteroids. Additional treatments included systemic antiviral medication in 4 patients, intravitreal antibiotics in 4 eyes, and pars plana vitrectomy in 4 eyes. Skin testing for vancomycin sensitivity showed negative results in 3 patients and was not performed in the others. Neovascular glaucoma developed in 7 eyes, and all eyes received intravitreal anti-vascular endothelial growth factor (VEGF) injection, panretinal photocoagulation, or both for retinal ischemia. Final visual acuity was less than 20/100 in 8 of 11 eyes. CONCLUSIONS: Postoperative HORV is an exceedingly rare and potentially devastating condition that can occur after otherwise uncomplicated cataract surgery. Although the precise cause remains unknown, this disease may represent a delayed immune reaction similar to vancomycin-induced leukocytoclastic vasculitis. Despite treatment with high-dose corticosteroids, antiviral medication, and early vitrectomy in many patients, visual outcomes typically were poor in this series. Early intervention with intravitreal anti-VEGF medication and panretinal photocoagulation may help to prevent additional vision loss resulting from neovascular glaucoma.

OPTICAL COHERENCE TOMOGRAPHY FINDINGS AND SURGICAL OUTCOMES OF TISSUE PLASMINOGEN ACTIVATOR-ASSISTED VITRECTOMY FOR SUBMACULAR HEMORRHAGE SECONDARY TO AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To study the relationship between morphologic findings using spectral domain optical coherence tomography and surgical outcomes in patients with submacular hemorrhage (SMH) secondary to age-related macular degeneration. METHODS: Medical charts of nine eyes of nine patients who underwent tissue plasminogen activator-assisted vitrectomy for SMH secondary to age-related macular degeneration were retrospectively reviewed. The preoperative height and lateral width of both SMH and pigment epithelial detachment documented with optical coherence tomography, were measured. The status of ellipsoid layers was also analyzed. RESULTS: Complete displacement of SMH from the fovea was achieved in all nine eyes. The preoperative status of the ellipsoid layer under the fovea was detectable in four eyes and absent in the remaining five eyes. Postoperative best-corrected visual acuity was significantly better in eyes with preoperative detectable ellipsoid layers (P < 0.01). Eyes with preoperative SMH heights <400 µm also exhibited better best-corrected visual acuity (P < 0.05). There was no significant correlation between postoperative best-corrected visual acuity and the specific features of pigment epithelial detachment, including height, lateral width, and number. CONCLUSION: The preoperative presence of detectable ellipsoid layers and a lower height of SMH may predict good visual prognosis. In contrast, no specific features of pigment epithelial detachment correlated with postoperative best-corrected visual acuity.