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R. Rajagopal, J. Davies, G. K. Shah, K. J. Blinder; Subretinal Tissue Plasminogen Activator and Bevacizumab for Large Subretinal Hemorrhage From Neovascular Age-Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2010;51(13):922.
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Management of large subretinal hemorrhage from wet age-related macular degeneration is controversial. The purpose of this study is to describe the outcomes of pars plana vitrectomy with subretinal injection of tissue plasminogen activator (tPA) and bevacizumab with pneumatic displacement in the treatment of this condition.
Retrospective, interventional case series of 6 eyes from 6 patients with recent subretinal hemorrhage who underwent surgery from October 2007 to July 2008 by two surgeons at a single academic center. A 23-gauge pars plana vitrectomy system was used. In some cases, one sclerotomy site was enlarged to accommodate a 20-gauge injection cannula with either a 39 or 41 gauge tip. A subretinal injection of tPA and bevacizumab was given, followed by an air-fluid exchange. Patients maintained face-down positioning post-operatively. Outcome measures were Snellen visual acuity, success in hemorrhage displacement, intra-operative and post-operative complications, and retreatments after surgery.
Mean patient age was 77 (range 68 - 89) years. Mean pre-op and post-op visual acuities were logMAR 1.904 (Snellen equivalent 2/150) and logMAR 1.471 (Snellen equivalent 20/400), respectively. Mean follow-up time after surgery was 181 (range 33 - 544) days. Subretinal hemorrhage was successfully displaced from the macula in all cases. Two of 6 patients required injection of either ranibizumab or bevacizumab during the follow-up period for reactivation of the choroidal neovascular complex. One patient, who was on warfarin therapy for deep venous thrombosis, had a recurrent submacular hemorrhage 16 months after surgery. No intra-operative or post-operative complications were reported.
Pars plana vitrectomy with subretinal injection of tPA and bevacizumab appears to be effective in displacing large subretinal hemorrhage. Patients tolerated this treatment well without ocular or systemic complications. Most patients did not need retreatment during the follow-up interval. Final visual acuity was limited by underlying chorioretinal atrophy and macular scarring.
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