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Figure 1. A 55-year-old woman had decreased vision in her left eye for 2 months. A, Fundus photograph showed a reddish brown submacular hemorrhage with an area of altered, yellow hemorrhage. B, Indocyanine green angiography revealed a hypofluorescent area with no hot spots. The probable cause was idiopathic polypoidal choroidal vasculopathy.

Figure 1. A 55-year-old woman had decreased vision in her left eye for 2 months. A, Fundus photograph showed a reddish brown submacular hemorrhage with an area of altered, yellow hemorrhage. B, Indocyanine green angiography revealed a hypofluorescent area with no hot spots. The probable cause was idiopathic polypoidal choroidal vasculopathy.

Figure 2. One day after intravitreous injection of tissue plasminogen activator (100 μg/0.1 mL) with perfluoropropane gas (0.3 mL), the unaltered submacular hemorrhage had resolved.

Figure 2. One day after intravitreous injection of tissue plasminogen activator (100 μg/0.1 mL) with perfluoropropane gas (0.3 mL), the unaltered submacular hemorrhage had resolved.

1.
Heriot W. Intravitreal gas and tPA: an outpatient procedure for subretinal haemorrhage. Paper presented at: Vail Vitrectomy Meeting; March 10-15, 1996; Vail, CO
2.
Krepler K, Kruger A, Tittl M, Stur M, Wedrich A. Intravitreal injection of tissue plasminogen activator and gas in subretinal hemorrhage caused by age-related macular degeneration.  Retina. 2000;20(3):251-256PubMedArticle
3.
Hassan AS, Johnson MW, Schneiderman TE,  et al.  Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.  Ophthalmology. 1999;106(10):1900-1907PubMedArticle
4.
Chen CY, Hooper C, Chiu D, Chamberlain M, Karia N, Heriot WJ. Management of submacular hemorrhage with intravitreal injection of tissue plasminogen activator and expansile gas.  Retina. 2007;27(3):321-328PubMedArticle
5.
Hattenbach LO, Klais C, Koch FH, Gümbel HO. Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions.  Ophthalmology. 2001;108(8):1485-1492PubMedArticle
Research Letters
June 2012

Intravitreous Tissue Plasminogen Activator With Pneumatic Displacement in Submacular Hemorrhage

Author Affiliations

Author Affiliations: Shri Bhagwan Mahavir Vitreoretinal Services, Tamil Nadu, India.

Arch Ophthalmol. 2012;130(6):795-796. doi:10.1001/archophthalmol.2011.1856

Submacular hemorrhage–induced retinal damage appears to vary directly with the duration of hemorrhage. Hence, many investigators have advocated early evacuation of subretinal hemorrhage to minimize these damaging effects. In 1996, Heriot1 presented the benefits of the minimally invasive procedure of enzymatically liquefying the submacular blood with tissue plasminogen activator (tPA) and displacing it with gas. Many studies have since shown good results with this procedure, but the exact time of the intervention is still debatable.2,3 Although there is no consensus, submacular bleeding for more than 28 days is generally believed to give poor results.4 We report a case of submacular bleeding for 60 days that showed dramatic clearing within a day with tPA and gas.

Report of a Case

A 55-year-old, nondiabetic, nonhypertensive woman of Asian Indian origin had sudden decreased vision in her left eye for 2 months. Her visual acuity was 20/20 OD and 20/200 OS. The left eye revealed a reddish brown mound of subretinal blood over the posterior pole, about 5 to 6 disc diameters in size. Some of the subretinal hemorrhage was altered and yellow, indicating a long duration (Figure 1A). Indocyanine green angiography revealed a hypofluorescent area corresponding to the area of subretinal blood, and no hot spot was found (Figure 1B). Provisional diagnosis of idiopathic polypoidal choroidopathy causing submacular bleeding was made. The left eye was treated with intravitreous tPA with perfluoropropane gas. Topical anesthesia was achieved with topical proparacaine hydrochloride, 0.5%, ophthalmic eyedrops. Irrigation of the conjunctival cul de sac with povidone-iodine, 5%, was performed. Commercial tPA, diluted with balanced salt solution to a concentration of 100 μg/0.1 mL, and 0.3 mL of pure perfluoropropane gas were then injected via a 30-gauge needle introduced through the pars plana into the vitreous cavity. A paracentesis was then performed to reduce the intraocular pressure. After ensuring optic nerve head perfusion, the eye was covered with a sterile eye pad and the patient was allowed to go home. The patient was advised to maintain a supine position for the first 6 hours to facilitate tPA diffusion through the retina and then remain prone for at least 8 hours a day for 5 days. The next day, the left eye showed complete resolution of the unaltered hemorrhage (Figure 2). Repeated indocyanine green angiography did not show any hot spots. Final best-corrected visual acuity was 20/30 after 2 months.

Comment

The size of the submacular hemorrhage has not been shown to affect the outcome of this procedure. Hassan et al3 showed good results even in large, thick submacular hemorrhages. There are conflicting reports with regard to the duration of submacular hemorrhage. In a series by Hattenbach et al,5 no eyes with a submacular hemorrhage duration longer than 21 days showed any improvement. However, in a series of 104 eyes, Chen et al4 did not find significant correlation with the duration of hemorrhage but most of the eyes were treated within 4 weeks. Despite the conflict, our case illustrates that it is worthwhile to attempt the use of tPA with gas even in longer-lasting hemorrhages where observation alone will likely lead to gross reduction of vision.

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Article Information

Correspondence: Dr Ratra, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Rd, Chennai, 600 006, Tamil Nadu, India (dhanashreeratra@hotmail.com).

Financial Disclosure: None reported.

References
1.
Heriot W. Intravitreal gas and tPA: an outpatient procedure for subretinal haemorrhage. Paper presented at: Vail Vitrectomy Meeting; March 10-15, 1996; Vail, CO
2.
Krepler K, Kruger A, Tittl M, Stur M, Wedrich A. Intravitreal injection of tissue plasminogen activator and gas in subretinal hemorrhage caused by age-related macular degeneration.  Retina. 2000;20(3):251-256PubMedArticle
3.
Hassan AS, Johnson MW, Schneiderman TE,  et al.  Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.  Ophthalmology. 1999;106(10):1900-1907PubMedArticle
4.
Chen CY, Hooper C, Chiu D, Chamberlain M, Karia N, Heriot WJ. Management of submacular hemorrhage with intravitreal injection of tissue plasminogen activator and expansile gas.  Retina. 2007;27(3):321-328PubMedArticle
5.
Hattenbach LO, Klais C, Koch FH, Gümbel HO. Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions.  Ophthalmology. 2001;108(8):1485-1492PubMedArticle
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