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T. Q. Kirk, C. J. Chen; Management of Massive Subretinal Macular Hemorrhage With Tissue Plasminogen Activator and Bevacizumab. Invest. Ophthalmol. Vis. Sci. 2010;51(13):1756.
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To present our surgical experience in treating massive subretinal (SR) macular hemorrhage by pars plana vitrectomy (PPV) with SR tissue plasminogen activator (t-PA) injection and concurrent intravitreal bevacizumab (Avastin®) injection. While combination therapy with bevacizumab and t-PA for SR hemorrhage has been reported in animal studies, there have not been any published reports regarding the clinical efficacy of this treatment strategy. This study evaluates the outcomes of this procedure.
This retrospective case series reviews 12 consecutive patients with massive SR macular hemorrhage. Diagnosis, age, visual acuity(VA), fluorescein angiogram, and coagulative status were evaluated. All patients underwent 23 gauge three port pars plana vitrectomy with approximately 25 ug t-PA injected by cannulation into the subretinal space, 1.25 mg bevacizumab intravitreal injection, and partial air-fluid exchange by a single surgeon (CJC). Postoperative 1 hour supine positioning was followed by upright positioning for 1 week.
11 patients had an underlying diagnosis of age related macular degeneration, and 1 patient had a ruptured retinal macroaneurysm. 42% of our patients were on anticoagulative therapy, 1 used coumadin, 1 used clopidogrel, 1 used aspirin/extended release dipyridamole, and 2 used 81mg aspirin. 83% of patients had stabilization or improvement of visual acuity at the 1 month postoperative visit. Average VA improved from 1.70 logMAR (n=12) preoperatively, to 1.50 logMAR (n=12) at 1 month post-op, and 1.20 log MAR (n=9) at 6 months post-op. 10 patients required repeat treatment with intravitreal bevacizumab to control their exudative macular degeneration; however, no subretinal hemorrhage recurrences were observed. 1 persistent hemorrhage was observed, and 3 hemorrhages had subtotal clearing, the remaining 8 responded with total clearing.
PPV with SR t-PA injection for massive SR hemorrhage has previously been reported, but not in conjunction with intravitreal bevacizumab. Anti-VEGF therapy has rapidly become the preferred treatment for exudative macular disease. This study demonstrates the usefulness of these two therapies used in conjunction to treat patients with exudative macular disease and massive SR hemorrhage.
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