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Various management strategies exist for resolution of thick hemorrhagic exudative AMD
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WAIKOLOA, Hawaii — Despite more conservative methods used by his peers, one clinician said he attacks large hemorrhages related to exudative age-related macular degeneration with surgery.
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"If they come in with a thick hemorrhage, I operate or I offer them the surgery," Allen C. Ho, MD, said at Retina 2008, held here. "If it's a thin hemorrhage, I'll still consider injection of an anti-VEGF therapy because oftentimes [patients] can do well."
Dr. Ho defined a thick hemorrhage as greater than 1 mm in thickness. When these hemorrhages present, he said that he uses a 41-g subretinal needle and a 25-g cannula to complete a vitrectomy, install submacular tissue plasminogen activator (tPA) at 25 µg/0.1 cc, inject a gas bubble and perform a fluid exchange with pneumatic displacement of the hemorrhage. The patient is then positioned face down, he said.
"I have had some reasonable cases and some home runs that keep you coming back when you do the vitrectomy, do the submacular tPA and put a full gas bubble," he said.
One pearl Dr. Ho shared was to inject tPA in several locations, particularly along the inferior border.
"You want the tPA to kind of swirl around the whole area of blood to liquefy, but I do it inferiorly so I can begin to open that central space between the juncture of the large hemorrhage and attached retina inferiorly" to promote the displacement, he said.
If a hemorrhage is less than 1 mm in thickness, Dr. Ho said he will not perform this procedure.
"With thin hemorrhages, surgery may not be necessary. In fact, I would say do not do surgery. The risks of surgery are not warranted in these cases," he said.
Dr. Ho said although some question whether anti-VEGF medications can permeate blood, he prefers to treat thin hemorrhage exudative AMD patients with Lucentis (ranibizumab, Genentech) or Avastin (bevacizumab, Genentech).
"I tend to treat because I'm not willing to not treat exudative AMD," Dr. Ho said.