Kerala Journal of Ophthalmology

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

Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage


G Mahesh, Dinesh Rungta 
 Department of Vitreoretinal Services, Giridhar Eye Institute, Cochin, Kerala, India

Correspondence Address:
Dr. G Mahesh
Vitreoretinal Services, Giridhar Eye Institute, Cochin - 682 020, Kerala
India

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.



How to cite this article:
Mahesh G, Rungta D. Tissue plasminogen activator-assisted surgical removal of massive subretinal hemorrhage.Kerala J Ophthalmol 2020;32:171-173


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 24 ];32:171-173
Available from: http://www.kjophthal.com/text.asp?2020/32/2/171/293303


Full Text



 Introduction



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



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}{Figure 2}{Figure 3}{Figure 4}

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



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.

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