Abstract
Purpose: :
Submacular hemorrhage has an unfavorable prognosis; 66 to 80% lose VA. Intraocular injection of rtPA may be an option for patents with hemorrhagic CNV and other forms of submacular hemorrhage. Controversy still exists about the usefulness and route of administration (intravitreal/subretinal) of intraocular rtPA.
Methods: :
Patients with submacular hemorrhage, treated with either intravitreal (group A: 16 patietns) or subretinal (group B: 26 patients) rtPA injection and gas tamponade were retrospectively analized. 10 to 20 µg of rtPA was injected subretinally through a 41G Teflon needle, while for intravitreal injection 40 µg were used. In both techniques SF6–air tamponade and semi–prone post–op positioning were employed. Mophologic and functional results as well as complications were compared.
Results: :
Both groups were comparable in patients' age, initial VA, duration and size of hemorrhage. In most of the patients (38/42 – both groups) submacular hemorrhage resulted from AMD. Four patients had hemorrhage associated with retinal arterial macroaneurysma (2 in each group) and one patient had idiopathic hemorrhage (group B). Follow–up period comprised in average 5,7 months (median: 3 months; range: 2 – 36 months). Hemorrhage displacement and resolution within 1 month post–op was much more common after subretinal injection (18 from 26 (75%) vs. 4 from 16 (25%)). Functional results were following: Group A: VA improvement (2 or more lines) at last follow–up : 2/16 (12%), VA decrease (2 or more lines): 3/16 (19%), stable VA: 11/16 (69%); Group B: improvement 5/26 (19%), worsening 2/26 (8%), stable 19/26 (73%). In 3 AMD cases resolution of hemorrhage allowed to perform PDT. Complications: Three patients in subretinal rtPA group with initial success developed recurrent submacular hemorrhage. Repeated rtPA injection did not improved VA. Retinal detachment soon after surgery occurred in 4 of 26 patients received subretinal rtPA and in none of 16 patients treated with intravitreal rtPA. Surgery (vitrectomy and silicon oil) allowed to reattach the retina in all 4 cases.
Conclusions: :
Subretinal injection of rtPA in submacular hemorrhage leads to faster blood displacement and resorption than intravitreal injection. However functional results are comparable and both approaches allow to maintain stable VA in majority of cases. In the presence of significant VA increase after subretinal rtPA injection in some cases, toxicity seems to be clinically insignificant. The major concern of the surgery is retinal detachment, which seems to be more common after subretinal injection.
Keywords: age-related macular degeneration • vitreoretinal surgery • drug toxicity/drug effects