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Carl S Wilkins, Neesurg Sunil Mehta, Chris Wu, Alexander Barash, Avnish Deobhakta, Richard B Rosen; Sub-retinal tPA injection with pars plana vitrectomy and air-fluid displacement of dense sub-macular hemorrhage. Invest. Ophthalmol. Vis. Sci. 2019;60(9):5755. doi: https://doi.org/.
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Fovea-involving sub-retinal hemorrhage is difficult to treat and may have devastating visual outcomes. We sought to investigate the potential benefit of pars plana vitrectomy (PPV) with sub-retinal alteplase (tPA) and intravitreal gas displacement for fovea-involving macular hemorrhage. This study aims to elucidate outcomes and identify patient subgroups who may benefit more from intervention.
A retrospective case series was performed of all patients who underwent PPV and had an associated pharmacy J-code for intraoperative tPA. Eighty-one patients fit inclusion criteria; 37 patients remained after exclusion. Reasons for exclusion included intravitreal tPA injection in office without surgery, insufficient follow-up, or insufficient documentation in the operative report despite a linked pharmacy code. Mean pre-operative, post-op month 1 and 3, and final visual acuity were measured using Snellen visual acuity. All visual acuities were converted into LogMAR for analysis.
The mean age was 68.2 years, with 54.1% females. The most common underlying etiology was exudative macular degeneration (43.2%), followed by undifferentiated (21.6%), polypoidal choroidal vasculopathy (18.9%), trauma-related choroidal neovascularization (8.1%), macroaneurysm (5.4%), and proliferative diabetic retinopathy (2.7%). Pseudophakic patients comprised 51.4%, phakic 40.5%, and aphakic or undocumented 8.1%. Eight patients (21.6%) were on anticoagulation or antiplatelet therapy. Ten total patients (27%) had complications including 4 vitreous hemorrhages (10.8%), 3 recurrent submacular hemorrhages (8.1%), 3 rhegmatogenous retinal detachments (8.1%), 1 phthisical eye (2.7%), and 1 corneal endothelial failure (2.7%). Mean pre-op visual acuity was 20/1239. Mean visual acuity at post-op month 1, month 3, and at last follow-up were 20/427 (p=0.0082), 20/267 (p=0.0028), and 20/215 (p=0.0005), respectively. Mean central subfield thickness on SD-OCT was 512.2 μm and 648.2 μm for predominantly sub-RPE heme and sub-retinal heme, respectively, and difference in mean visual acuity was not statistically significant by location of hemorrhage (p=0.481).
Sub-retinal tPA injection in combination with pars plana vitrectomy and air-fluid displacement of dense submacular hemorrhage appears to have modest efficacy in visual recovery, though long-term vision may be limited by underlying pathology.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.
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