Tips offered for managing subretinal macular hemorrhage

When directly administering tissue plasminogenactivator to manage subretinal macular hemorrhage in patients with age-related macular degeneration (AMD), patients' visual acuity about be at least 20/200, the clot should be less than 2 weeks old and preferably less than 1 week old, and administration should be facilitated using a rigid cannula through a self-sealing retinotomy, said Jonathan E. Sears, MD, of the Cleveland Clinic's Cole Eye Institute, United States.

Using a rigid cannula to inject plasminogenactivator into the clot lessens the possibility of further shearing of the photoreceptors as might occur with the use of a translocation device, Dr. Sears explained.

"The common occurrence of submacular hemorrhage-at least in my practice-has really decreased," he said. "Although this is a very good surgery, I'm hoping that it's a surgery, like many of our surgeries in the past, that might not be as necessary in the future."

This surgery is very effective for other bleeding in the macula, he noted.

Dr. Sears studied patients that had vision loss less than 14 days. All hemorrhages were secondary to AMD, and large hemorrhages that needed retinectomy were not included. Aspirin therapy was stopped in patients taking it, and warfarin sodium (Coumadin, Bristol-Myers Squibb) therapy was bridged with heparin. About one-third of the patients had used warfarin sodium preoperatively.

Patients were given complete ophthalmologic exams, three-port pars plans vitrectomy always was performed with elevation of posterior hyaloid, and a small retinotomy was made with a 32-g spatula.

"That's usually created through the temporal side of the macula, with the left eye using the left hand and the right eye using the right hand," Dr. Sears explained.

Through the small, linear retinotomy, a 32-g rigid cannula was used to introduce t-PA; total volume used ranged from 0.3 to 0.4 ml.

Patients were face-up for at least 1 hour and then were placed upright to ensure proper head position.

Average patient age was 81 years, average duration of the submacular hemorrhage was less than 2 weeks, and average follow-up was 17.2 months.

"In half of our patients, we had total displacement of the blood, and in about half of the patients we had somewhere less than a total displacement but not enough to take the patient back to surgery," Dr. Sears said of the results.

Procedural complications included recurrence of the submacular hemorrhage within 3 months in three patients. One patient had a retinal detachment. There were no complications in 13 patients.

Postoperatively, about half the patients required additional treatment, the most common of which was photodynamic therapy, performed in five patients.

Postoperative visual acuity improved to more than 20/200 in more than half the patients. Eighty-eight percent had stable or improved VA. Nine patients experienced a total clearing of the macular hemorrhage, and eight patients had partial clearing.

Because of the small sample size, Dr. Sears said that it is unclear determination which lesion types would most benefit from this procedure.