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Mark Sherman, Charles Barr, Shlomit Schaal; Functional and Anatomical Outcomes of Tissue Plasminogen Activator (tPA) Treatment for Submacular Hemorrhage Associated with Exudative Macular Degeneration (ExAMD): A Comparative Analysis Between Intra-vitreal and Sub-retinal tPA injected Patients. Invest. Ophthalmol. Vis. Sci. 2013;54(15):3304.
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To analyze and to compare the effect of treatment with tPA, injected either intra-vitreally or sub- retinally, on the final visual acuity and the size of the final sub-retinal scar in submacular hemorrhage due to ExAMD.
29 ExAMD patients with acute submacular hemorrhage were randomized between 2 groups. 19 patients treated with 25G vitrectomy, subretinal tPA injection (25mcg/0.05cc), and intravitreal injection of SF6 20% gas. 10 patients received in-office intravitreal tPA injection (50mcg/0.1cc), followed by intravitreal injection 0.3 cc of 100% C3F8 gas. Functional outcome was determined by Snellen VA. Anatomical outcome was determined by fundus photography, FA, and OCT used to define the initial size of the subretinal hemorrhage and the final scar size. Differences in functional and anatomical outcomes were compared between the two treatment groups.
Patients in the two groups did not differ in age (p=0.74), gender (p=0.55), initial visual acuity (p=0.33), the initial area of the sub-macular hemorrhage (p=0.25), initial intra-ocular pressure (p=0.34), follow- up duration (p=0.22), lens status of the affected eye (p=0.66), duration of time from initial ExAMD diagnosis (p=0.25), the number of previously given intravitreal Bevacizumab injections (p=0.43), or the time frame from the last given injection to the acute sub-macular hemorrhage (p=0.43). Although final visual acuity improved significantly in both treatment groups (p=0.045), the final visual acuity was better preserved in the subretinal tPA injected group (20/125±20/76) compared to patients treated with intravitreal tPA (20/224±20/52), p=0.025. Increase in size of the final disciform scar was inversely correlated with initial pre-treatment submacular hemorrhage dimension (r=-0.82, p=0.012). Patients treated with subretinal tPA achieved 40.1±54.1% reduction in final scar area, in contrast to a smaller decrease in the area of the scar in patients treated with intravitreal tPA (27.5±35.2%; p=0.001).
Treatment with tPA improves functional and anatomical outcomes in patients with submacular hemorrhage due to ExAMD. Subretinal injection is superior in preserving visual acuity and in reducing the size of the final disciform scar compared to intravitreal injection.
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