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Deepthi Reddy, Matthew Oltmanns, Mathew Sapp, Robert Morris; Vitrectomy with Intentional Bullous Retinal Detachment to Mobilize and Move Recent Subfoveal Hemorrhage in Age-related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2013;54(15):3339.
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© ARVO (1962-2015); The Authors (2016-present)
To describe a novel “Mobilize and Move” (M&M) approach and determine the ability of extensive subretinal recombinant tissue plasminogen activator (rtPA) irrigation during vitrectomy with gas tamponade to rapidly mobilize and move recent subfoveal hemorrhage in Age-Related Macular Degeneration (ARMD) to an extra-foveal location.
This is a retrospective consecutive case series of patients (N=6) with ARMD and recent subfoveal hemorrhage that underwent the M&M technique. A standard 3-port 25 gauge pars plana vitrectomy is performed. Next, using a 32 gauge Lambert needle, rtPA, 25µG/0.1mL, is injected into the subretinal space in the area of the clot, loosening the clot from its adherences to the retina and RPE (“Mobilize”). Additional rtPA is injected into the subretinal space contiguous with the area of hemorrhage but outside the infero-temporal arcade, in an area of normal retina. A total of 0.5-0.7 cc is injected into the subretinal space. This step creates an area that the loosened clot can move into via subsequent pneumatic displacement (“Move”). Fifty percent of fluid is removed from the vitreous cavity (air-fluid exchange), followed by an exchange of air for 15% sulfur hexafluoride. Patients are then positioned 4 hours supine followed by face down positioning for 12-14 hours, to facilitate pneumatic displacement.
Snellen acuity improved from 20/1074 pre-op to 20/135 3-6 weeks post-op (P=0.03). Visual acuity past 6 months post op (mean 9.33 months) was 20/148 (P=0.07). All 6 eyes had total clearing of subfoveal blood on post-op week 1.
After a recent submacular hemorrhage, the rapid resolution of blood is the primary controllable variable in pursuing optimal return of visual acuity/central visual field. Such resolution is most certainly achieved by mobilizing and moving the hemorrhage as here described, rather than by awaiting spontaneous resolution, or employing lesser measures. In large hemorrhages, consideration can be given to M&M vitrectomy, simply to resolve the submacular component, as an alternative to high risk “giant retinotomy” with silicone oil. As the power of the study increases with the addition of patients, we will be better able to determine the role of this technique in the management of ARMD complicated by submacular hemorrhage.
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