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R. Maturi; Sub–retinal tissue Plasminogen activator (TPA) injection for the treatment of acute subretinal hemorrhages associated with Age–related Macular Degeneration . Invest. Ophthalmol. Vis. Sci. 2004;45(13):3137.
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© ARVO (1962-2015); The Authors (2016-present)
Purpose: To determine if surgical intervention with vitrectomy, subretinal tPA injection, and 24 hour positioning would provide visual benefit in patients with acute, large subretinal hemorrhages associated with AMD. Methods: The study is designed as a non–comparative, retrospective, interventional case series. We identified 28 patients with severe exudative AMD with associated subretinal hemorrhage who underwent the above procedure over the last 4 years and were treated by a single surgeon. 26 patients had a follow–up of at least 3 months, and 12 of these patients had one year follow–up data available. Results: Major findings: 16 of 26 patients had improved vision after treatment. Two patients had decreased vision at 3 months (both were 20/400 preoperative and were Counting fingers(CF) postoperatively). 11 of 12 patients at one year had continued stable or improved vision. Postoperative procedures: 4 patients required PDT, and 2 required focal laser treatment after tPA displacement of hemorrhage. TPA dosage: Most patients got 20 mcg of tPA. 4 got 30 mcg (2/4 had Va improvement). 2 got 40 mcg. Neither patients had any visual improvement. Duration of visual loss: 16/26 had visual loss for less than 14 days prior to surgery. 3 patients had visual loss for 38, 60, 90 days each – none showed an improvement in vision despite successful displacement of hemorrhage. One patient with 18 days of visual loss prior to surgery improved to 20/70 (20/200 preop). Conclusions: Safety: There were no major instances of severe visual loss due to recurrent hemorrhage in this group during the study period. There were no major complications with the procedure itself besides the one case of retinal detachment. Functional benefit: A majority of patients had stable or improved vision that was sustained at one year. Even patients with no significant objective change in vision reported improved functioning with daily tasks due to a decrease in the size of the central scotoma. tPA dosing: The data presented supports the potential benefit of up to 30 mcg of tPA (2/4 patients with this dose improved). Higher doses may be harmful as both of our high dose tPA patients had no improvement in vision. However, the subretinal hemorrhage size was significantly greater in these two patients – making a direct comparison difficult. General conclusions: Patients with large subfoveal hemorrhages due to macular degeneration can be considered for subfoveal tPA displacement of hemorrhage with relatively low risk. The duration of bleed should be less than three weeks, and visual acuity must be poor (20/200 or less). Up to 30mcg of tPA may be used for the procedure.
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