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Emilia Maggio, Antonio Polito, Massimo Guerriero, Grazia Pertile; Recombinant Tissue Plasminogen Activator for Submacular Hemorrhage Displacement in Age-Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2014;55(13):2299.
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The visual prognosis of submacular hemorrhages (SMH) secondary to age-related macular degeneration (AMD) is potentially devastating when left untreated. The displacement of SMH with intravitreal recombinant tissue plasminogen activator (rtPA) and gas injection may allow extrafoveal resorption of the hemorrahage, postoperative diagnostic testing and, potentially, subsequent treatments.
We retrospectively analyzed medical records of all patients with acute SMH secondary to AMD treated with a single 0.05-mL intravitreal injection of 50 μg alteplase, 0.3 mL of 100% sulphur hexafluoride gas (SF6) and face down positioning for 1 week from 2004 to 2012. The majority of eyes also received additional treatments for AMD following two months after the procedure. The main outcome measures were the displacement of the hemorrhage, complication rate and visual acuity (VA) at 1 month after the procedure, at 1 year and at the last follow-up visit.
Seventy-eight eyes were eligible for the study. One week after the procedure, the hemorrhage was successfully displaced in all eyes. No significant complications from the procedure were identified. Mean follow-up was 26 months (min 6 months; max 8 years). Additional treatments during the follow-up were: anti-VEGF intravitreal injections (32,1%), macular translocation (26.9%), autologous RPE-choroid patch graft (3,8%) and membranectomy (5,1%). Twenty-five patients (32,1%) did not undergo additional treatments. Mean VA at baseline was 1,7(0,94) logMar. It significantly improved to 1,26(0,79) logMAR at 1 month and 1,29(0,78) logMAR at 1 year (p=0,00001). At the last follow-up visit mean VA was 1.35(0,87) logMAR. Worst VA was found after longer follow-up period and in eyes who did not receive additional treatments.
The use of intravitreal rtPA and gas injection is safe and effective to displace recently developed SMH in patients with AMD and to prevent macular damage from retinotoxic blood components such as hemosiderin, fibrin and iron. Although the final visual outcomes may be limited by the progression of AMD, significant visual restoration is possible in selected cases after the application of additional treatments.
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