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 Table of Contents  
SURGICAL CORNER
Year : 2020  |  Volume : 32  |  Issue : 2  |  Page : 171-173

Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage


Department of Vitreoretinal Services, Giridhar Eye Institute, Cochin, Kerala, India

Date of Submission23-May-2020
Date of Acceptance01-Jun-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. G Mahesh
Vitreoretinal Services, Giridhar Eye Institute, Cochin - 682 020, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_64_20

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  Abstract 


We describe the surgical technique of managing a case of massive subretinal hemorrhage (SRH) using tissue plasminogen activator [tPA], followed by vitrectomy and SRH drainage.

Keywords: Massive subretinal hemorrhage, tissue plasminogen activator, vitrectomy


How to cite this article:
Mahesh G, Rungta D. Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage. Kerala J Ophthalmol 2020;32:171-3

How to cite this URL:
Mahesh G, Rungta D. Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage. Kerala J Ophthalmol [serial online] 2020 [cited 2020 Nov 26];32:171-3. Available from: http://www.kjophthal.com/text.asp?2020/32/2/171/293303




  Introduction Top


Massive subretinal hemorrhage (SRH) is defined as a thick hemorrhage extending beyond the temporal arcades, or sometimes beyond the equator, which involves at least 2 quadrants of the retina.[1] SRH is an important cause of sudden visual loss. The visual outcome for patients is typically poor, especially if the hemorrhage is thick, involves the fovea, and covers a large area of the macula.[2] SRH has been strongly associated with anticoagulation, antiplatelet therapy, and coagulopathies.[3]

Recent advances in vitreoretinal surgical techniques over the past decade facilitate removal of SRHs from the subretinal space in the macular area.[4] However, when an SRH is massive and extends peripherally to form large hemorrhagic retinal detachments, it is difficult to displace or evacuate the subretinal clots by pneumatic displacement by intravitreal injection of expansile gas with tissue plasminogen activator (tPA) or without tPA.[5],[6] Thompson and colleagues showed poor visual outcome by the removal of the blood clot with pars plana vitrectomy, subretinal TPA, and gas and concluded that cases of massive SMH respond better to blood clot removal than displacement.[7]

To minimize surgically induced complications, we performed modified surgical procedure consisting of intravitreal injection of tPA before operation and subsequent vitrectomy and drainage of SRH through the small retinotomies using active and passive extrusion and silicone oil tamponade. We report a case of massive SRH causing profound visual loss, which was resolved with this less invasive surgical procedure.


  Case Report Top


A 77-year-old male patient presented with a history of sudden loss of vision in his left eye for the last 3 days. He was a known case of ischemic heart disease with diabetes mellitus and hypertension. He did not give any history of trauma. Assessment of best-corrected visual acuity showed only the ability to perceive hand movements in the left eye compared to 6/6 in the right eye. Slit-lamp examination of the anterior segment showed pseudophakia in both eyes with normal intraocular pressures. Fundus examination of the left eye showed a massive subretinal hemorrhage with sub- retinal pigment epithelium (RPE) hemorrhage extending from the posterior pole to the inferior and temporal midperiphery with hemorrhagic retinal detachment [Figure 1]. The right eye fundus showed mild nonproliferative diabetic retinopathy changes. Ultrasound B scan showed the presence of submacular hemorrhage with hemorrhagic retinal detachment in the left eye [Figure 2]. Patient was taken up for surgery with informed consent. Surgical procedure is described below. After 6 weeks, we observed that SRH was clearing well [Figure 3]. After 24 weeks, subretinal blood had totally disappeared from the macula with altered blood in inferior periphery and attached retina. Silicone oil removal was done after 28 weeks. At 34 weeks, visual acuity improved to 6/18 [Figure 4].
Figure 1: Preoperative fundus picture showing massive subretinal hemorrhage

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Figure 2: Ultrasound B-scan showing massive subretinal hemorrhage

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Figure 3: Postoperative picture at 6 weeks showing improvement

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Figure 4: Final fundus picture at 34 weeks

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Surgical steps

After peribulbar anesthesia and cleaning and draping, 75 microgram tPA is injected via pars plana using a 30G needle. The patient was made to lie down in the table for 30 min. Then, a 23-gauge vitrectomy was done. Two retinotomies were made in the area of SRH trying to keep the retinotomies as above the horizontal meridian as possible. Perfluorocarbon liquid was placed in the posterior pole and subretinal blood was drained slowly with flute needle. This was repeated till maximum drainage was done. Then, fluid–air exchange was done, followed by endolaser around the retinotomies. Silicone oil was injected.


  Discussion Top


The therapeutic principle of this surgical procedure was based on two synergistic effects: pharmacologically induced subretinal hemolysis by intravitreal tPA and subsequent drainage of liquefied blood by small retinotomies intraoperatively and by silicone oil tamponade postoperatively. Submacular hemorrhage is an important cause for sudden visual loss needing immediate intervention. Submacular hemorrhage is seen in cases of age-related macular degeneration, idiopathic polypoidal choroidal vasculopathy, ruptured macroaneurysm, and trauma. Due to shearing effect of blood clot and iron toxicity released from hemoglobin, SRH can cause irreversible damage of the retinal photoreceptors, leading to profound visual impairment and thus an ophthalmic emergency.[8] If it is involving only macula, just pneumatic displacement can be tried. This was published by the same authors.[6],[9] Other methods such as intravitreal gas along with antivascular endothelial growth factor drugs also is reported to work well. In a massive bleed, only surgical removal will help in salvaging eye. To minimize permanent retinal damage, speedy removal of subretinal hemorrhage is recommended, preferably within 7 days of the onset of bleeding to prevent permanent retinal damage.[10] Dose of tPA should be carefully considered as it can cause retinal toxicity, such as a decreased amplitude in electroretinography and atrophy of photoreceptors. In our case, intravitreal injection of 75 microgram tPA was used immediate preoperatively.[11],[12],[13],[14],[15] Subretinal tPA has been used as a surgical adjunct during vitrectomy to dissolve submacular clots. Problem here will be tPA has to be injected in multiple areas subretinally using 40-gauge needle due to the enormous amount of blood. Sometimes, laser photocoagulation around retinotomies may not take up due to the blood. The limited success in final visual outcome and the risks of complication have directed efforts toward less invasive treatment.[16] On using intravitreal tPA preoperatively in our case, we reduced the risk of retinal toxicity compared with a direct dose of subretinal tPA and avoided retinal and RPE damage.

In summary, we successfully displaced a massive subretinal hemorrhage using intravitreal tPA injection preoperatively, followed by vitrectomy and silicone oil tamponade. Postoperative visual outcome was good with clearing of subretinal hemorrhage.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fine HF, Iranmanesh R, Del Priore LV, Barile GR, Chang LK, Chang S, et al. Surgical outcomes after massive subretinal hemorrhage secondary to age-related macular degeneration. Retina 2010;30:1588-94.  Back to cited text no. 1
    
2.
Bennett SR, Folk JC, Blodi CF, Klugman M. Factors prognostic of visual outcome in patients with subretinal hemorrhage. Am J Ophthalmol 1990;109:33-7.  Back to cited text no. 2
    
3.
Brown GC, Tasman WS, Shields JA. Massive subretinal hemorrhage and anticoagulant therapy. Can J Ophthalmol 1982;17:227-30.  Back to cited text no. 3
    
4.
Haupert CL, McCuen BW 2nd, Jaffe GJ, Steuer ER, Cox TA, Toth CA, et al. Pars plana vitrectomy, subretinal injection of tissue plasminogen activator, and fluid-gas exchange for displacement of thick submacular hemorrhage in age-related macular degeneration. Am J Ophthalmol 2001;131:208-15.  Back to cited text no. 4
    
5.
Hassan AS, Johnson MW, Schneiderman TE, Regillo CD, Tornambe PE, Poliner LS, et al. Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement. Ophthalmology 1999;106:1900-6.  Back to cited text no. 5
    
6.
Mahesh G, Giridhar A, Saikumar SJ, Elias A. Intravitreal gas for submacular haemorrhage. Indian J Ophthalmol 2003;51:349-50.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Thompson JT, Sjaarda RN. Vitrectomy for the treatment of submacular hemorrhages from macular degeneration: A comparison of submacular hemorrhage/membrane removal and submacular tissue plasminogen activator-assisted pneumatic displacement. Trans Am Ophthalmol Soc 2005;103:98-107.  Back to cited text no. 7
    
8.
Singh P, Singh R, Kishore KS, Vig VK, Singh R, Singh B. Intravitreal tissue plasminogen activator in submacular haemorrhage. Indian J Ophthalmol 1999;47:254-5.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Gopalakrishan M, Giridhar A, Bhat S, Saikumar SJ, Elias A, N S. Pneumatic displacement of submacular hemorrhage: Safety, efficacy, and patient selection. Retina 2007;27:329-34.  Back to cited text no. 9
    
10.
Lewis H. Intraoperative fibrinolysis of submacular hemorrhage with tissue plasminogen activator and surgical drainage. Am J Ophthalmol 1994;118:559-68.  Back to cited text no. 10
    
11.
Johnson MW, Olsen KR, Hernandez E, Irvine WD, Johnson RN. Retinal toxicity of recombinant tissue plasminogen activator in the rabbit. Arch Ophthalmol 1990;108:259-63.  Back to cited text no. 11
    
12.
Bell JE, Shulman JP, Swan RJ, Teske MP, Bernstein PS. Intravitreal versus subretinal tissue plasminogen activator injection for submacular hemorrhage. Ophthalmic Surg Lasers Imaging Retina 2017;48:26-32.  Back to cited text no. 12
    
13.
Gok M, Karabaş VL, Aslan MS, Kara Ö, Karaman S, Yenihayat F. Tissue plasminogen activator-assisted vitrectomy for submacular hemorrhage due to age-related macular degeneration. Indian J Ophthalmol 2017;65:482-7.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Kitagawa Y, Shimada H, Mori R, Tanaka K, Yuzawa M. Intravitreal tissue plasminogen activator, ranibizumab, and gas injection for submacular hemorrhage in polypoidal choroidal vasculopathy. Ophthalmology 2016;123:1278-86.  Back to cited text no. 14
    
15.
Mizutani T, Yasukawa T, Ito Y, Takase A, Hirano Y, Yoshida M, et al. Pneumatic displacement of submacular hemorrhage with or without tissue plasminogen activator. Graefes Arch Clin Exp Ophthalmol 2011;249:1153-7.  Back to cited text no. 15
    
16.
Kamei M, Tano Y, Maeno T, Ikuno Y, Mitsuda H, Yuasa T. Surgical removal of submacular hemorrhage using tissue plasminogen activator and perfluorocarbon liquid. Am J Ophthalmol 1996;121:267-75.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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