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P. Goeminne, F. Hamon, L. Cardoen; Combined Treatment of Submacular Hemorrhage with Pneumatic Blood Displacement and Transpupillary Thermotherapy in Patients with Age-related Macular Degeneration and Subfoveal Choroidal Neovascularization . Invest. Ophthalmol. Vis. Sci. 2003;44(13):1751.
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Purpose: To evaluate a new therapeutic approach in the management of submacular hemorrhage (SMH), and preserve self-sufficiency of the elder. To improve the prognosis of SMH in ARMD with subfoveal CNV by treating the consequence (SMH) and the cause (CNV). Methods: We have analyzed data from twenty-two eyes of 20 patients with SMH treated between January 2000 and October 2002. We used a limited, posterior vitrectomy with removal of the posterior hyaloid in order to maximize flexibility of the retina and optimal capability of blood displacement. We didn't use injection of the fibrinolytic agent recombinant tissue plaminogen activator (rt-PA) but only pure sulfur hexafluoride (SF6) injected via the pars plana. Facedown positioning was recommended for about eight hours. Then, patients were asked to alternate prone positioning and walking a little, allowing active and quick blood displacement. We excluded patients with massive thick SMH and big macular folds, because we think pneumatic displacement is not the good solution . Results: There was 7 men and 13 women, with a mean age of 83 years (ranged 64 - 96 ). The size of the SMH ranged from 1 to 15 Macular Photocoagulation Study disc areas. Mean duration of SMH was two weeks (ranged 2 – 18 days). The mean follow-up period was 12,7 months . Surgery resulted in good blood displacement in all eyes. Preoperative Visual acuity (VA) ranged from 20/ to hand motion. Final VA improved in 18 eyes (82%) by 2 lines or more, worse in two eyes.The mean visual acuity improvement was 3,4 lines. The mean delay for treatment with TTT was 3 weeks after surgery. TTT was performed when blood wasn't on the subfoveal area anymore, because of the risk of a high retinal absorption and an atrophic result. No fovea burn was observed in any patient in our experiment. Majority of the eyes initially presented an occult CNV, often a minimally classic . No recurrence of SMH was observed, but some CNV did in a predominantly classic form, eligible to Photodynamic therapy (PDT). OCT and angiography demonstrated stabilization of the CNV, subretinal fibrosis and some partially macular atrophic areas for all the eyes. Conclusion: This study seems to confirm the possibility to combine treatments in SMH and to improve prognosis of such a serious disease. Association of a minimal surgery and TTT may help practitioners to manage some difficult cases. CR: None
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