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

Wilkins, Carl S.; Mehta, Neesurg; Wu, Chris Y.; Barash, Alexander; Deobhakta, Avnish; Rosen, Richard B.

doi:10.1136/bmjophth-2019-000394

Cited by 19 publications

(23 citation statements)

References 17 publications

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“…In 2015, Kim et al [ 16 ] reported that the most common cause of SMH in South Korea was nAMD (52.9%), followed by PCV (37.3%), RAM (5.9%), and lacquer cracks (3.9%). Other surgical studies of SMH in different geographical areas showed that the cause of SMH was nAMD in 80%–90% of cases and RAM in 5%–10% of cases [ 1 , 17 , 18 ]. In the current study, the cause of SMH was nAMD in approximately 70% of cases (tnAMD 17% and PCV 50%) and RAM in approximately 30%, and this percentage of RAM was higher than in previous reports.…”

Section: Discussionmentioning

confidence: 99%

Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group

Kimura

Araki²,

Yasukawa³

et al. 2022

PLoS ONE

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Purpose To evaluate the clinical characteristics, treatment trends, and visual prognosis of submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) and retinal arterial macroaneurysm (RAM). Methods This retrospective study enrolled 187 Japanese patients with SMH at 10 institutions from 2015 to 2018. Medical records including SMH etiology, best-corrected visual acuity (BCVA), fundus photographs, optical coherence tomography images, and selected treatments were analyzed. Results Major causes of SMH were typical nAMD (tnAMD) (18%), polypoidal choroidal vasculopathy (PCV) (50%) and RAM (29%). Age, male/female ratio, baseline BCVA, central retinal thickness, and involved retinal layers were significantly different between etiologies (all P<0.0001). Treatment with anti-vascular endothelial growth factor drugs with and without intravitreal gas injection was chosen for half of eyes in the tnAMD and PCV groups, whereas vitrectomy was performed in 83.7% of eyes with RAM. The final BCVA improved significantly from baseline in the PCV and RAM groups (P = 0.0009, P<0.0001) and final BCVA was significantly better in the PCV group at a level similar to the other groups (P = 0.0007, P = 0.0008). BCVA improvement from baseline was significantly greater in the RAM group compared with the tnAMD (P = 0.0152) and PCV (P = 0.017) groups. Multivariate analysis revealed better final BCVA was significantly associated with younger age (P = 0.0054), better baseline BCVA (P = 0.0021), RAM subtype (P = 0.0446), and no tnAMD (P = 0.001). Conclusions The characteristics of, and treatment strategy for, SMH were different between the underlying diseases. Anti-vascular endothelial growth factor treatment with or without expansile gas was mainly chosen for SMH in tnAMD and PCV, whereas vitrectomy with gas was the most common treatment for RAM, and the higher rate for vitrectomy might result in the greater BCVA improvement in the RAM group than in the other groups. Final BCVA was better in PCV, RAM, and tnAMD, in that order, because patients with PCV were younger and had better baseline BCVA.

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Section: Discussionmentioning

confidence: 99%

Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group

Kimura

Araki²,

Yasukawa³

et al. 2022

PLoS ONE

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“…For example, toxic effects of blood located subretinally, with early PR degeneration and subsequent cell death, have been proven. Even more, blood clots are known to produce fibrin-mediated tractional damage in different retinal layers [ 47 ]. Exudative AMD is the most frequent cause underlying SMH, but there are others such as polypoidal choroidal vasculopathy, undifferentiated and traumatic choroidal neovascularization (CNV), proliferative diabetic retinopathy and retinal arterial macroaneurysm [ 47 ].…”

Section: Indications For Subretinal Injectionsmentioning

confidence: 99%

“…Even more, blood clots are known to produce fibrin-mediated tractional damage in different retinal layers [ 47 ]. Exudative AMD is the most frequent cause underlying SMH, but there are others such as polypoidal choroidal vasculopathy, undifferentiated and traumatic choroidal neovascularization (CNV), proliferative diabetic retinopathy and retinal arterial macroaneurysm [ 47 ]. CNV can be considered the most common cause of SMH associated with AMD [ 20 ].…”

Section: Indications For Subretinal Injectionsmentioning

confidence: 99%

Subretinal Injection Techniques for Retinal Disease: A Review

Irigoyen

Alonso

Sanchez-Molina

et al. 2022

JCM

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Inherited retinal dystrophies (IRDs) affect an estimated 1 in every 2000 people, this corresponding to nearly 2 million cases worldwide. Currently, 270 genes have been associated with IRDs, most of them altering the function of photoreceptors and retinal pigment epithelium. Gene therapy has been proposed as a potential tool for improving visual function in these patients. Clinical trials in animal models and humans have been successful in various types of IRDs. Recently, voretigene neparvovec (Luxturna®) has been approved by the US Food and Drug Administration for the treatment of biallelic mutations in the RPE65 gene. The current state of the art in gene therapy involves the delivery of various types of viral vectors into the subretinal space to effectively transduce diseased photoreceptors and retinal pigment epithelium. For this, subretinal injection is becoming increasingly popular among researchers and clinicians. To date, several approaches for subretinal injection have been described in the scientific literature, all of them effective in accessing the subretinal space. The growth and development of gene therapy give rise to the need for a standardized procedure for subretinal injection that ensures the efficacy and safety of this new approach to drug delivery. The goal of this review is to offer an insight into the current subretinal injection techniques and understand the key factors in the success of this procedure.

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“…5–11 The other approach in treating SMH is PPV with subretinal rt-PA advocated as the primary treatment of choice by some authors. 12–14…”

mentioning

confidence: 99%

“…[5][6][7][8][9][10][11] The other approach in treating SMH is PPV with subretinal rt-PA advocated as the primary treatment of choice by some authors. [12][13][14] The two approaches in the management of SMH have invariably been used mutually exclusive of each other. The Manchester SMH Management Protocol is an attempt to combine the two treatment options in a more practical and pragmatic step-wise management pathway.…”

mentioning

confidence: 99%

Step-Wise Approach to the Management of Submacular Hemorrhage Using Pneumatic Displacement and Vitrectomy

Chew

Ivanova

Patton

et al. 2022

Retina

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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 mg/0.1 mL. If unsuccessful, a prompt pars plana vitrectomy with subretinal recombinant tissue plasminogen activator 50 mg/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.

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

Cited by 19 publications

References 17 publications

Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group

Differences in clinical characteristics and treatment outcomes of submacular hemorrhage caused by age-related macular degeneration and retinal macroaneurysms: A multicenter survey from the Japan Clinical Retina Study (J-CREST) group

Subretinal Injection Techniques for Retinal Disease: A Review

Step-Wise Approach to the Management of Submacular Hemorrhage Using Pneumatic Displacement and Vitrectomy

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