A New Method of Subretinal Injection of Tissue Plasminogen Activator and Air in Patients With Submacular Hemorrhage

Novelli, Fernando José De; Preti, Rony Carlos; Monteiro, Mário Luiz Ribeiro; Nóbrega, Mário Junqueira; Takahashi, Walter Yukihiko

doi:10.1097/iae.0000000000001491

Cited by 24 publications

(17 citation statements)

References 13 publications

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“…Visual outcomes in our patients are like those previously reported in several exudative AMD studies,7 8 11 and had greater improvement than in others 9 10. One study by Gonzalez-Lopez et al reported slightly better outcomes with intervention earlier than 8 days, worse outcomes by area of haemorrhage and a similar overall final BCVA to this cohort at roughly 12-month follow-up 12.…”

Section: Discussionsupporting

confidence: 87%

“…While prior studies have generally been limited to exudative AMD, this study includes all patients with SRMH regardless of underlying diagnosis. Prior wet AMD series have demonstrated modest visual recovery, anatomic success and relatively few adverse events 7–11. Some natural history studies have suggested worse outcomes of SRMH in patients with CNV, while interventional studies have demonstrated improved outcomes in patients continuing to receive anti-VEGF treatments post-operatively 4 9.…”

Section: Discussionmentioning

confidence: 99%

“…Chang et al published a large, multicentre retrospective series of patients with exudative AMD and SRMH, demonstrating successful anatomic result in 82% of patients, with modest improvement in visual recovery postoperatively, greatest in patients with CNV who continued anti-VEGF injections at follow-up 9. Recent studies in patients with AMD, polypoidal choroidal vasculopathy (PCV) and other causes of SRMH have promoted the addition of air in the tPA injected to enhance displacement of coagulated blood 10 11…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage

Wilkins

Mehta

et al. 2020

BMJ Open Ophth

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ObjectiveFovea-involving subretinal haemorrhage is challenging to manage with uncertain visual outcomes. We reviewed outcomes of patients with fovea-involving macular haemorrhage treated with pars plana vitrectomy (PPV) and subretinal tissue plasminogen activator (tPA) with pneumatic displacement.Methods and AnalysisThis is a retrospective interventional case series. All patients with submacular haemorrhage who underwent PPV with subretinal tPA injection were included. Reasons for exclusion encompassed patients who underwent intravitreal tPA injection in the office without surgery, insufficient follow-up or documentation. Primary outcomes of interest were postoperative visual acuity (VA) at month 1 and 3. Secondary outcomes were median VA at month 3 by location of haemorrhage and underlying diagnosis.ResultsThirty-seven total patients were included. The mean age was 68.2 years, with 54.1% (20/37) females. The most common aetiology was exudative macular degeneration (43.2%), followed by undifferentiated choroidal neovascularisation (CNV) (18.9%), polypoidal choroidal vasculopathy (18.9%), traumatic CNV (10.8%), macroaneurysm (5.4%) and proliferative diabetic retinopathy (2.7%). Median preoperative VA was 20/2000, postoperative month 1 was 20/347 (p<0.01), improving to 20/152 (p<0.01) at month 3. Proportion of patients gaining vision 3+ lines in vision was 15/36 (42%). Mean preoperative central subfield thickness on optical coherence tomography was 512.2 µm for sub-retinal pigment epithelium haemorrhage and 648.2 µm for subretinal haemorrhage (p=0.48). Difference in VA by diagnosis was not significant (p=0.60).ConclusionsPPV with subretinal tPA injection and pneumatic displacement of submacular haemorrhage offers modest visual recovery for a diverse group of patients. Location of haemorrhage or specific diagnosis may not predict outcome.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage

Wilkins

Mehta

et al. 2020

BMJ Open Ophth

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“…In our opinion what makes our technique more practical and easy to use is that all operative steps can be performed by a single surgeon ( 14 ). No additional time is needed for clot lysis or to prepare special injection devices ( 15 ). There are no studies that compare the functional results of these surgical techniques, so at the moment the choice is strictly related to the comfort and possibilities of the surgeon.…”

Section: Discussionmentioning

confidence: 99%

Subretinal alteplase injections in massive subretinal hemorrhage due to age‑related macular degeneration: A case report series

et al. 2020

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This report describes a series of cases with massive subretinal hemorrhage (SRH) due to age-related macular degeneration (AMD) treated by subretinal alteplase injections. In all cases, the surgical technique consisted in 25-gauge pars plana vitrectomy (PPV) and alteplase injection under the retina using a 38-gauge cannula. After the fluid-gas exchange, bevacizumab injection was performed in all patients. Three cases of SRH in which this technique was used, as well as their evolution at one week and one month postoperatively are described. Visual acuity was hand motion in all three cases at presentation. After surgery, a significant anatomical and functional improvement was noted in all cases. One month postoperatively, none of the patients had blood under the macula, and visual acuities significantly improved to 0.8, 0.2 and 0.16 (decimal fraction). A consistent reduction of central retinal thickness was observed on optical coherence tomography (OCT) from the first week postoperatively. No intra and postoperative complications were noted. Subretinal alteplase injection proved as a viable solution in these severe SRH with early presentation. There was no need to change the systemic anticoagulant and antiaggregant therapy. Bevacizumab intravitreal injection at the end of surgery has an important role in preventing further bleeding.

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“…Therefore, if the blood clot can liquefy earlier, the success rate of operation and surgical effect may be better. Some authors have also used suprachoroidal cavity injection of tissue plasminogen activator 4-5 d after SCH to liquefy the clot[20-22]. Suprachoroidal cavity injection is an intraocular operation which can be performed in some complications, such as retinal detachment, vitreoretinal traction, and vitreous hemorrhage.…”

Section: Discussionmentioning

confidence: 99%

Sub-Tenon’s urokinase injection-assisted vitrectomy in early treatment of suprachoroidal hemorrhage: Four cases report

Chai¹,

Ai²,

Deng³

et al. 2018

WJCC

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BACKGROUNDSuprachoroidal hemorrhage (SCH) is a rare but potentially catastrophic ocular event. Surgery for SCH is often challenging because of the difficulty in resolving the retinal and choroidal detachment. Here, we describe a novel surgical technique in which urokinase is administered by sub-Tenon’s injection to target an organized clot in SCH prior to drainage.CASE SUMMARYA consecutive case series of four eyes with serous and hemorrhagic choroidal detachments secondary to cataract surgery or trauma was documented to evaluate the feasibility of using a sub-Tenon’s urokinase injection-assisted 23-gauge and 20-gauge incision to drain choroidal detachments. Urokinase (2000 IU) was given by sub-Tenon’s injection one day before surgery for clot liquefaction. A 23-gauge infusion line was placed in the anterior chamber. A 20-gauge incision was created in the suprachoroidal space 3.5 mm from the limbus. After drainage, pars plana vitrectomy was performed because of concomitant pathology that demanded this additional procedure. Visual acuity, ocular findings, the timing of surgical interventions, surgical procedures, and outcomes were retrospectively reviewed in four patients. Postoperative follow-up of the patients ranged from 6 to 24 mo (mean, 13 mo). After the treatment, all patients achieved excellent anatomical recovery.CONCLUSIONSub-Tenon’s urokinase injection-assisted vitrectomy makes clot liquefaction happen in the early treatment stage, resulting in marked stability during the procedure.

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A New Method of Subretinal Injection of Tissue Plasminogen Activator and Air in Patients With Submacular Hemorrhage

Abstract: Supplemental Digital Content is Available in the Text.

Cited by 24 publications

References 13 publications

Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage

Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage

Subretinal alteplase injections in massive subretinal hemorrhage due to age‑related macular degeneration: A case report series

Sub-Tenon’s urokinase injection-assisted vitrectomy in early treatment of suprachoroidal hemorrhage: Four cases report

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