Displacement of macular hemorrhage obtained with subretinal rTPA injection

In a case series in Nantes, visual improvement was achieved in two-thirds of the patients.

Issue: January 1, 2007

ByMichela Cimberle

PARIS – Pneumatic displacement of submacular hemorrhage by subretinal injection of recombinant tissue plasminogen activator was effective in restoring visual function in a series of patients with age-related macular degeneration.

“This method allows good anatomical and functional results, allowing, potentially, postoperative treatment of the neovascular membranes, reduction of the scotoma and subsequent low-vision rehabilitation,” Jean-François Le Rouic, MD, of the Clinique Sourdille of Nantes, France, said at the annual meeting of the French Society of Ophthalmology.

The prognosis for eyes with submacular hemorrhage secondary to AMD is generally poor, he said.

The subretinal blood is toxic to the outer retina and causes irreversible photoreceptor damage. In addition, in most AMD patients this complication occurs when the disease has already produced a considerable loss of vision and, according to the Submacular Surgery Trial, has severely affected the contralateral eye in 53% of cases. If untreated, the hemorrhage, in combination with the natural progression of the age-related disease, tends to produce a rapid decline of visual acuity, leading to legal blindness. Size and thickness of the hemorrhage negatively influence the prognosis.

Two examples of retinal submacular hemorrhage.

Images: Le Rouic JF

Several surgical approaches

Because no medical treatment can cure this condition, several surgical approaches have been developed, that aim to clear the blood from the macula.

“The first approaches were based on transretinal blood drainage and surgical removal of the choroidal neovascular membranes that originated the hemorrhages. However, these methods produced several complications, such as retinal detachment in 15% to 25% of the cases and severe proliferative vitreoretinopathy,” Dr. Le Rouic said.

A less traumatic approach was developed in 1996 by Heriot, based on intravitreal injection of recombinant tissue plasminogen activator (rTPA), pneumatic displacement of the blood and face-down positioning of the patient.

This procedure can be performed in an outpatient setting, is relatively simple and has few complications, but the efficacy is limited to new, small-size hematomas.

More recently, in 2001 and 2004, Haupert and Olivier published the results of a novel technique, consisting of pars plana vitrectomy to allow subretinal injection of rTPA through a microcannula, followed by fluid-air exchange and postoperative prone positioning.

“This new method also allowed for displacement of dense, large-size hemorrhages without retinal manipulation,” Dr. Le Rouic said.

Series shows successful treatment in one patient. This is the preoperative image of the hemorrhage.	At 15 days postop, the patient is ready to receive CNV treatment with PDT.

At 9 months postop, the patient has achieved a final visual acuity of 20/40.

Encouraging results

The medical records of 45 patients (46 eyes) treated with this technique between 2004 and 2006 at the Clinique Sourdille were retrospectively reviewed. The mean age of the patients was 77 years, and the majority (37/45) were women. A large percentage (41%) were taking anticoagulants or anti-aggregating agents.

All patients presented with submacular hemorrhage secondary to AMD. The period between symptoms and treatment was less than 1 month (mean 13 days). Half of the patients had visual acuity worse than 20/200 in the contralateral eye.

After pars plana vitrectomy, a solution consisting of saline and 125 mg/mL of rTPA was injected under the macula. This created a small area retinal detachment through which the hemorrhage was evacuated. Fluid-air exchange was performed, and the patients were kept in a prone position for 48 hours.

“We followed these patients for a mean period of 9 months (range 3 to 29 months). The hemorrhage was drained in 91% of the cases (42/46 eyes),” Dr. Le Rouic said.

Visual results were limited by the progression of the underlying macular disease, ranging from light perception to 20/40. Only 17% of the eyes achieved a final visual acuity of better than 20/200.

“However, an improvement in [visual acuity] was obtained in two-thirds (65%) of the eyes. Of the remaining eyes, 24% were stable and 11% lost some [visual acuity] lines,” he said.

Postoperatively, 46% of the patients underwent further treatment with either photodynamic therapy, perifoveal or extrafoveal laser therapy or transpupillary thermotherapy, and more than half of the patients with visual acuity worse than 20/200 in the contralateral eye (13/23) joined a low-vision rehabilitation program.

No complications occurred in 74% of the eyes. The most frequent complications were retinal detachment, occurring in 9% of the eyes (4/46), and recurrence of the hemorrhage after the procedure in 11% of the cases (5/46).

“Given the severity of this condition, these results are encouraging,” Dr. Le Rouic said. “We believe that this method is an interesting option that should be offered to motivated patients. It seems to be more effective than Heriot’s procedure and definitely safer than the transretinal removal of blood and neovascular membranes.”

He added that a further improvement of results may be obtained in the future with the concomitant use of an anti-vascular endothelial growth factor injection.

For more information:

Jean-François Le Rouic, MD, can be reached at Clinique Sourdille, 8 rue Camille Flammarion, 44000 Nantes, France. 33-2-40-591516; fax: 33-2-40-597073; e-mail: jflr@caramail.com.

Michela Cimberle is an OSN Correspondent based in Treviso, Italy, who covers all aspects of ophthalmology. She focuses geographically on Europe.