Clinical profile and management outcomes of traumatic submacular hemorrhage

Abstract

PurposeTo evaluate the anatomical and functional outcome of patients with traumatic submacular hemorrhage (SMH).MethodsA retrospective, interventional case series of patients presenting between January 2016 and April 2018 was carried out at 4 tertiary eye care centers of India. Medical records of the patients with a history of blunt trauma and SMH were retrospectively reviewed. The intervention done was any one of the following: pneumatic displacement with 0.3 ml of intravitreal gas [100% perfluoropropane (C3F8) gas], pneumatic displacement with intravitreal 0.3 ml of 100% C3F8 gas combined with 100 μg/0.1 ml of recombinant tissue plasminogen activator (r-tpa), pars plana vitrectomy (PPV) with subretinal r-tpa and gas tamponade. The primary outcome measures included change in visual and anatomical status.ResultsTwenty eyes of 20 patients with blunt trauma were analyzed. Thirteen patients had small size SMH, 5 patients had medium size SMH, and 2 patients had massive size SMH. Sixteen patients had a favorable functional outcome, and eighteen patients had favorable anatomical outcome. The size and duration of post-traumatic SMH did not significantly affect the anatomical (P = 0.123) or functional (P = 0.293) outcome in our study. The patients who presented with initial visual acuity of 6/60 or better showed better functional outcome, which was statistically significant (P = 0.007).ConclusionMinimally non-invasive procedure including intravitreal r-tpa and gas appear to be effective in the displacement of post-traumatic SMH.

Postoperative Multimodal Analysis in Successful Gas Displacement of a Submacular Hemorrhage

“…Here, we have reported a case in which early treatment with gas vitrectomy yielded successful displacement of the submacular blood as well as release of vitreoretinal traction at the margins of the posterior tear. Moreover, a strict prone positioning regimen allowed the sealing of the tear, preservation of the retinal anatomical structure, and displacement of the submacular blood outside the central area of the macula; all the previous facts have also been demonstrated in other studies [ 1 , 3 , 4 , 6 ]. The use of postoperative multimodal imaging analysis with serial SS-OCT, SD-OCT, mfERG, and microperimetry in this case highlights a possible clinical and functional contribution to the study and knowledge of this vision-threatening traumatic condition.…”

“…Numerous approaches have been described for the displacement of SMH, including vitrectomy with the use of intravitreal or subretinal recombinant tPA (r-tPA), intravitreal gas tamponade, postoperative positioning [ 4 ], and pneumatic displacement with or without tPAs [ 6 ]. Ultimately, the preferred technique is defined by the duration and the extent of the SMH in addition to the surgeon's skill and preference [ 9 ].…”

“…In cases complicated by posterior retinal tears, we consider that the release of vitreoretinal traction is of paramount importance and the pneumatic displacement without tPA injection followed by a strict prone position, in cases complicated by posterior retinal tears such as the one reported here, is less invasive and potentially less toxic than the tPA-assisted surgical drainage of the SMH. The mechanism involves moving the blood away from the subfoveal space by using the long-acting gas buoyancy effect to displace the blood from the submacular foveocentral photoreceptors [ 1 , 2 , 4 , 7 , 11 ].…”

“…This condition is defined as the presence of a significant hemorrhage under the neurosensory macula [ 2 ], which is generally caused by the contusional breakdown of the blood–retina barrier [ 3 ]. Besides ocular trauma, the most common conditions that may cause an SMH are pathological myopia, pathological submacular choroidal neovascularization, polypoidal choroidal vasculopathy, arterial macroaneurysms, and presumed ocular histoplasmosis syndrome [ 2 , 4 ]. Blunt ocular trauma with SMH is a major cause of severe vision loss [ 4 ], usually affecting young patients and causing several pathological conditions such as commotion retinae, choroidal rupture, macular hole, subretinal and macular hemorrhage, retinal vascular rupture, vitreous hemorrhage, retinal pigment epithelial edema and healed scarring, retinal dialysis, macular infarction, traumatic optic neuropathy, optic nerve avulsion [ 2 ], and even retinal tears.…”

“…Besides ocular trauma, the most common conditions that may cause an SMH are pathological myopia, pathological submacular choroidal neovascularization, polypoidal choroidal vasculopathy, arterial macroaneurysms, and presumed ocular histoplasmosis syndrome [ 2 , 4 ]. Blunt ocular trauma with SMH is a major cause of severe vision loss [ 4 ], usually affecting young patients and causing several pathological conditions such as commotion retinae, choroidal rupture, macular hole, subretinal and macular hemorrhage, retinal vascular rupture, vitreous hemorrhage, retinal pigment epithelial edema and healed scarring, retinal dialysis, macular infarction, traumatic optic neuropathy, optic nerve avulsion [ 2 ], and even retinal tears. Clinical and histopathological studies have shown that prolonged contact of the blood catabolic products with photoreceptors in the subretinal space worsens the prognostic and visual outcomes [ 5 ].…”