Vol.14
No. 1, Januray, 2004
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
-
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.
-
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.
-
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.
