|Year : 1999 | Volume
| Issue : 4 | Page : 254-255
Intravitreal tissue plasminogen activator in submacular haemorrhage
P Singh, R Singh, KS Kishore, VK Vig, B Singh
Dr Sohan Singh Eye Hospital, Amritsar, India
Dr Sohan Singh Eye Hospital, Amritsar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Singh P, Singh R, Kishore K S, Vig V K, Singh B. Intravitreal tissue plasminogen activator in submacular haemorrhage. Indian J Ophthalmol 1999;47:254-5
Submacular haemorrhage is a major cause of sudden visual loss in age-related macular degeneration (AMD). If left untreated it often results in permanent central visual loss. We present our experience in the use of intravitreal tissue plasminogen activator (fPA) in a 65-year-old male with submacular haemorrhage.
| Case Report|| |
A 65-year-old male presented with sudden decrease in vision in the right eye of 7 days duration with no history of ocular trauma. The patient was on radiotherapy for carcinoma oesophagus but was ambulatory and mentally alert. There was no systemic history of diabetes mellitus or hypertension. His best corrected visual acceity was counting fingers in both eyes. The left eye had suffered a similar sudden drop in visual acuity 4 years before.
On examination the patient had grade 2 nuclear sclerosis in both eyes; however, the adnexa, ocular motility, anterior segment and intraocular pressure (IOP) were within normal limits. Fundus examination. showed a thick submacular haemorrhage covering about 7 disc areas within the arcades in the right eye [Figure - 1], and a disciform scar in the left eye. We diagnosed wet AMD with submacular haemorrhage in the right eye. Four options were available to us: to leave the patient alone; surgical removal of the submacular blood without tPA; tPA-assisted removal of blood, and lastly, intravitreal tPA with gas injection. In view of the patient's physical condition, we took the last option.
We injected 100μg of tPA in 0.1 ml and 0.4 ml of SF6 gas through the pars plana in the right eye, followed by paracentesis and monitoring of the optic disc. After one hour the patient was asked to remain prone.
When examined 12 hours later, the submacular blood had shifted below the inferior arcade [Figure - 2]. Fluoreslein angiography showed an ill-defined choroidal neovascular membrane (CNVM). Indo-cyanine green video angiography revealed an active juxtafoveal CNVM [Figure - 3], which was treated with argon laser photocoagulation. Visual acuity of the patient improved to 6/60, N36 in 15 days and 6/18, N10 at one-month follow-up. This level of visual acuity was maintained at 5-months follow-up. The patient died 6 months later due to carcinoma oesophagus-related complications.
| Discussion|| |
Submacular haemorrhage may be secondary to choroidal neovascular membrane (AMD, POHS, choroidal rupture, angioid streaks), ocular trauma, arterial macro-aneurysms and pathological myopia. It causes irreversible damage to the photoreceptor outer segments by the shearing effect of the clot, apart from the mechanical obstruction to metabolic exchange between the retinal pigment epithelium (RPE) and the outer retina. The iron released from the haemoglobin may also cause outer retinal cell toxicity.
Submacular haemorrhage is an emergency and it should be removed at the earliest (not later than one week, though in our case the tPA was injected on the 9th day) for a favourable visual outcome. Surgical removal of blood has been tried but the extensive surgery required has led to poor visual outcome. The use of clot-lysing agents represented a significant breakthrough.tPA-assisted removal of subretinal blood significantly minimises intraoperative trauma with better visual results. Intravitreal tPA with gas is a relatively new technique, which is minimally invasive. We found it to be extremely useful, producing gratifying results in our patient.
| References|| |
Lewis H. Intraoperative fibrinolysis of submacular haemorrhage with tissue plasminogen activator and surgical drainage. Am J Ophthalmol
Peyman GA, Schulman JA. Intravitreal Surgery
. 2nd ed. Norwalk, Connecticut, USA:Appleton & Lange; 1994. p 654-62.
Holz FG, Pauleikhoff D. Altersabhangige Makula-degeneration
.1st ed. Berlin, Germany: Springer-Verlag; 1997. p 141-53.
[Figure - 1], [Figure - 2], [Figure - 3]