Intravitreal Versus Subretinal Administration of Recombinant Tissue Plasminogen Activator Combined With Gas for Acute Submacular Hemorrhages Due to Age-Related Macular Degeneration

Abstract

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.

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

“…As described previously, subretinal rtPA is very effective for the treatment of submacular hemorrhages [6,7,16,17,18,20]. Without any contradictions, our results confirmed this statement.…”

“…was performed using a standard high-speed volume scan of 19 sections with 5.7 mm length (20° × 15°), with a distance of 240 µm centered around the foveal region. Similarly to the recently published semimanual ITK-Snap analysis [16], we analyzed three foveal images: the central scan through the fovea and the upper and lower scan in the foveal region. Since we wanted to support therapy decisions in real-time, we used a classification method that does not require additional software installation and can be performed with the standard Spectralis OCT software.…”

“…These include, for example, thickness [13] and size [14,15] of the hemorrhage or the elevation of the retina due to the subretinal clot [13,15]. Until now, there is only one recent systematic investigation of the functional and anatomical benefits corresponding to different anatomical origins of the hemorrhage [16]. Most studies are case series of 10-20 eyes based only on subretinal hemorrhages (SRH), subpigment epithelial hemorrhages (SPH), and combined subretinal and subpigment epithelial hemorrhages (CH) [13,14,15,17].…”

“…In a case series, Lincoff et al [19 ]found SPH to be resistant to displacement with intravitreal gas application. De Jong et al [16 ]have recently investigated the outcome of subretinal versus intravitreal application of rtPA and found no substantial difference when treated either with subretinal or intravitreal injections. Using a semimanual contour-based image analysis method (ITK-Snap) of OCT images in order to differentiate between SRH and SPH, de Jong et al's group found the subretinal rather than the subpigment epithelial proportion of the blood clot to be responsive to subretinal rtPA treatment.…”

“…Using a semimanual contour-based image analysis method (ITK-Snap) of OCT images in order to differentiate between SRH and SPH, de Jong et al's group found the subretinal rather than the subpigment epithelial proportion of the blood clot to be responsive to subretinal rtPA treatment. However, in the study discussed above [16], only 12 patients were included, while cases with a hemorrhage thickness >1,250 µm were excluded. Even if the ITK-Snap analysis seems to be sophisticated, it is restrictively applied in the day-to-day practice because of the complicated software support and prolonged office computing procedures.…”