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.
Ratra D, Basia A. Intravitreous Tissue Plasminogen Activator With Pneumatic Displacement in Submacular Hemorrhage. Arch Ophthalmol. 2012;130(6):795-796. doi:10.1001/archophthalmol.2011.1856
Author Affiliations: Shri Bhagwan Mahavir Vitreoretinal Services, Tamil Nadu, India.
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.
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.
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.
Correspondence: Dr Ratra, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, 18 College Rd, Chennai, 600 006, Tamil Nadu, India (firstname.lastname@example.org).
Financial Disclosure: None reported.