Abstract

 

Results of Tissue Plasminogen Activator in Submacular Hemorrhage
Vishali Gupta, Ramandeep Singh, Amod Gupta, MR Dogra

ABSTRACT

Purpose: To evaluate the efficacy of intravitreal tissue plasminogen activator (TPA) in submacular homorrhage.

Methods: Seven patients with submacular hemorrhage due to subfoveal sub retinal neovascular membrane (2 eyes), unknown etiology (3 eyes), post blunt-trauma (2 eyes) were treated with intravitreal TPA and intravitreal injection of expansile gas.

Results: The mean age was 36.12 years and the mean duration of submacular bleed before TPA injection was 12.28 days. The visual acuity improved to 6/9 or better in 4 eyes and 6/60 to 6/36 in 3 eyes.  An inflammatory reaction that resolved with corticosteroids was seen in 5 eyes.

Conclusions: Intravitreal TPA was effective and safe in treatment of submacular hemorrhage.

INTRODUCTION
Sub retinal hemorrhage affecting the macula may occur secondary to a variety of etiologies and often results in significant visual loss. There are two broad categories of posterior segment abnormalities that may result in the development of sub macular hemorrhage: those not involving choroidal neovascularisation and those involving choroidal newvascularisation.  In the absence of choroidal neovascularisation, sub macular hemorrhage may be seen in individuals with high myopia, after blunt or penetrating ocular trauma, in asociation with retinal deatchment, in a variety of retinal vascular diseases including retinal arterial macro aneurysms and sickle cell disease, in association with intra-ocular tumors and as a complication of retinal and vitreous surgery.

MATERIAL AND METHODS
We reviewed retrospectively the medical records of seven consecutive patients with macular hemorrhage due to subfoveal sub retinal neovascular membrane (2 eyes), unknown etiology (3 eyes), post blunt-trauma (2 eyes). Ocular finding were analyzed in each case by external examination, slit lamp biomicroscopy looking for neovascularisation, applanation tonometery, gonioscopy and indirect ophthalmoscopy.  They received intravitreal TPA (50 microg) and expansile gas i.e. SF6 (0.3ml) for thrombolysis and displacement of sub macular hemorrhage. After the procedure, patients maintained facedown positioning for 1 to 5 days.

RESULTS
Among the seven patients, there were 5 males and 2 females.  The mean age was 36.12 years. Various causes of hemorrhage were subfoveal sub retinal neovascular membrane (2 eyes), unknown etiology (3 eyes), and post blunt-trauma (2 eyes).  The mean duration of sub macular bleed before TPA injection was 12.28 days.  All the patients received intravitreal TPA (50 microg) and expansile gas i.e. SF6 (0.3 ml). Patients were face down position for 1-5 days.  Initial visual acuity was less than 6/60 in all the cases. The visual acuity improved to 6/9 or better in 4 eyes, which included  three cases of trauma and I case with unknwn etiology, Rest three of them had visual acuity 6/60 to 6/36, which included both the cases of ARMD and one case of unknown etiology. We did notice an inflammatory reaction in 5 eyes that resolved with corticosteroids and high intra-ocular pressure in 3 eyes.  There was no complication relating to prone position.

DISCUSSION
Sub macular hemorrhage is often a visually devastating development and represents a clinical challenge to ophthalmologists, although newer vitreoretinal surgical techniques may enhance the ability to successfully remove hemorrhage from the subretinal space, the natural history, as well as the outcome after surgical intervention, include the underlying etiology of the hemorrhage, the preexisting status and health of macula, the duration, thickness, and extent of hemorrhage, intraoperative trauma and the both intraoperative and post operative complications.

Pars plana vitrectomy to evacuate massive sub retinal hemorrhage can improve visual acuity, but final visual acuity is limited by the underlying disease.1 Doses of intravitreal TPA ranging form 18 to 50 microg and an expansile gas bubble are safe and effective in displacing sub macular hemorrhage in patients with ARMD.2 Final visual acuity was limited by the underlying presence of end-stage ARMD. Toxic and hypoxic damage of foveolar photoreceptors by sub retinal hemorrhage can be prevented by early and minimal invasive fibrinolytic therapy.

Intravitreal administered SF6 alone may have a role in the management of selected cases of neovascular AMD complicated by significant sub macular hemorrhage.3 Our results were similar to other studies in various parts of the world.  Complications faced by us were also similar and taken care of in the end.  Intravitreal TPA with gas tamponade is effective in cases of short duration and one with normal and healthy macula behind.

REFERENCES

  1. Ibanez HE, Williams OF, Thomas MA, Ruby AJ, Meredith TA, Boniuk, Grand MG. Surgical management of sub macular hemorrhage.  A series of 47 consecutive cases. Arch Ophthalmol 1995; 113(1):62-9.

  2. Handwerger BA, Blodi BA, Chandra SR, Olsen TW, Stevens TS. Treatment of sub macular hemorrhage with low-dose intravitreal tissue plasminogen activator injection and pneumatic displacement. Arch Ophthalmol 2001; 119(1):28-32.

  3. Oaneshvar H, Kertes PJ, Leonard BC, Peyman GA. Management of sub macular hemorrhage with intravitreal sulfur hexafluoride: a pilot study. Can J Ophthalmol 1999; 34(7): 385-8.   

Address for Correspondence
Dr. Vishali Gupta, Deptt. of Ophthalmology, PGIMER, Chandigarh