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Peter Kally, Michael Chua, Danielle Lo, Scott E Brodie, Kenneth Wald; Outcomes of subretinal high-dose tissue plasminogen activator injection in massive submacular hemorrhage. Invest. Ophthalmol. Vis. Sci. 2019;60(9):5792.
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Massive submacular hemorrhage (SMH) is a known complication of age-related macular degeneration (AMD) that can lead to irreversible vision loss. Past studies well document the use of subretinal tissue plasminogen activator (tPA) at 25-50μg with gas tamponade to attempt heme displacement. The purpose of this study is to evaluate the anatomic outcomes and retinal toxicity of eyes receiving high-dose 125μg subretinal tPA infusion during pars plana vitrectomy (PPV) and gas tamponade in the treatment of SMH.
A retrospective chart review was performed including patients with massive submacular hemorrhage from exudative AMD who underwent PPV with subretinal infusion of 0.1 mL of 125μg/0.1mL tPA (total dose of 125 μg) using a previously described technique of standard vitrectomy system fluid control unit coupled to a 41-gauge cannula on an insulin syringe for controlled semi-automated delivery, this was followed by fluid-air exchange with gas tamponade. Pre- and postoperative imaging and visual acuity (VA) were assessed, as well as postoperative electroretinography (ERG) evaluation. Visual acuities were converted into logarithm of minimum angle of resolution (logMAR) scale for statistical analysis.
A total of three eyes from three patients were included in the study. The minimum follow up period was 31 days (mean: 37, range: 31-45). The change from mean pre-operative logMAR VA of 1.26 (SD 0.52) improved to a mean post-operative VA of 1.01 (SD 0.61) at 1 month. Color fundus photo comparison revealed partial to complete clearing of heme without fibrosis (Fig. 1). Postoperative adverse events included recurrent subretinal hemorrhage in 1 eye. ERG review performed at 1 month post-operative follow up showed 30% decreased photopic response (1 eye), 50% amplitude reduction in the setting of recurrent SMH (1 eye), and normal symmetric responses (1 eye).
Massive SMH treated with high-dose subretinal tPA, PPV, and gas tamponade was associated with favorable anatomic outcomes and no definite evidence of tPA induced retinal toxicity by ERG. Anatomic improvement was only associated with modest functional improvement in visual acuity. Further study is needed to validate these preliminary results.
This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.
Figure 1: (A, C) Pre-operative fundus photographs of SMH. (B, D) 1-month post-operative photographs with partial clearing of SMH.
Figure 2: ERG showing 30% decreased photopic amplitude.
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