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| BRIEF REPORT |
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| Year : 2003 | Volume
: 51
| Issue : 4 | Page : 349-350 |
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Intravitreal gas for submacular haemorrhage
G Mahesh, A Giridhar, Seshadri J Saikumar, A Elias
Giridhar Eye Institute, Kerala, India
Correspondence Address:
G Mahesh
Giridhar Eye Institute, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 14750625 
Submacular haemorrhage is an important cause for sudden visual loss needing immediate intervention. We report a case of submacular haemorrhage causing profound visual loss, which resolved after intravitreal injection of perfluoropropane (C3F8) gas followed by strict prone positioning Keywords: Submacular haemorrhage, perfluoropro-pane gas
How to cite this article:
Mahesh G, Giridhar A, Saikumar SJ, Elias A. Intravitreal gas for submacular haemorrhage. Indian J Ophthalmol 2003;51:349-50 |
| Case report | |  |
A 50-year-old healthy female presented with a history of sudden loss of vision in the right eye of five days' duration. She did not give a history of trauma, previous ocular or systemic disease. The best-corrected visual acuity was hand movements in the right eye and 6/6, N6 in the left eye. Slitlamp examination of the anterior segment showed early lens opacities in both eyes, with normal intraocular pressures. Fundus examination of the right eye showed dense subretinal haemorrhage 6-8 disc diameters in size under the macula extending below the arcade [Figure - 1]. The left eye fundus was normal. Fundus fluorescein angiogram showed blocked choroidal fluorescence corresponding to the haemorrhages [Figure - 2] in the right eye. The left eye was unremarkable and there was no evidence of age-related macular degeneration.
Considering the recent onset and the lack of alternatives she was advised intravitreal C3F8 injection and prone positioning. Peribulbar anaesthesia was given and pinky ball was applied to make the eye soft. 0.3 ml of perfluoropropane gas was injected briskly as a single bubble via supero temporal pars plana 3.5mm from the limbus. She was advised to maintain a strict prone position for 2 weeks. She was put on topical antibiotic corticosteroid combination and cycloplegic. The following day, there was minimal displacement of the blood from under the fovea and no splashing of the displaced haemorrhage. On the next follow-up visit, a week after the injection, blood was nearly completely displaced from the macula and there was breakthrough vitreous haemorrhage. Visual acuity was 6/60. One month later she had complete clearing of submacular haemorrhage and visual acuity was 6/6 [Figure - 3]. Fluorescein angiogram was repeated. It showed retinal pigment epithelium window defect adjacent to an area of blocked choroidal fluorescence temporal to the fovea suggestive of retinal pigment epithelium rip [Figure - 4].
| Discussion | | |
Submacular haemorrhage is seen in cases of age-related macular degeneration, idiopathic polypoidal choroidal vasculopathy, ruptured macroaneurysm, and trauma. When it extends under the fovea it can cause profound visual impairment. The haemorrhage causes irreversible damage of the retinal photoreceptors by the shearing effect of the clot apart from the toxicity due to the iron released from the haemoglobin.[1] It is therefore necessary to consider a modality of treatment, that can remove this blood. Use of Intravitreal tPA along with gas is a well documented method of treatment in such a clinical situation. [1],[2],[3],[4],[5],[6]The disadvantage of using tPA is its high cost. Moreover, a large portion of the drug is wasted, as only a small quantity is required to treat a single case. The therapeutic safety margin is also narrow for tPA.[6] The complications of tPA are not well documented. Considering these factors some authors have reported the use of intravitreal gas injection alone for the treatment of submacular haemorrhage. [7],[8]
We report a rather surprising result of intravitreal gas injection in a case of submacular haemorrhage. Within the first week after injection, the blood was displaced from under the fovea. Later there was mild vitreous breakthrough of blood. Fluorescein angiogram showed evidence of a retinal pigment epithelium rip temporal to the fovea and no features of choroidal neovascular membrane. Indocyanine green angiography could have been helpful to rule out idiopathic polypoidal choroidal vasculopathy. Though this is an isolated case report we feel the use of intravitreal gas injection alone with strict prone positioning is a good alternative to the use of tPA in selected cases of submacular haemorrhage.
| References | | |
| 1. | Singh P, Singh R, Kishore KS, Vig VK, Singh R, Singh B. Intravitreal tissue plasminogen activator in submacular haemorrhage. Indian J Ophthalmol 1999;47;254-55.  |
| 2. | Handwerger BA, Blodi BA, Chandra SR, Olsen TW, Stevens TS. Treatment of submacular haemorrhage with low dose intravitreal tissue plasminogen activator injection and pneumatic displacement. Arch Ophthalmol 2001;119: 28-32. [ PUBMED] [ FULLTEXT] |
| 3. | Johnson MW. Pneumatic displacement of submacular haemorrhage. Curr Opin Ophthalmol 2000;11:201-6. [ PUBMED] [ FULLTEXT] |
| 4. | Hattenbach LO, Klais C, Koch FH, Gumbel HO. Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular haemorrhage under various conditions. Ophthalmology 2001;108:1485-92. [ PUBMED] [ FULLTEXT] |
| 5. | Krepler K, Kruger A, Tittl M, Stur M, Wedrich A. Intravitreal injection of tissue plasminogen activator and gas in subretinal haemorrhage caused by age-related macular degeneration. Retina 2000;20:251-56. [ PUBMED] [ FULLTEXT] |
| 6. | Kokame GT. Vitreous haemorrhage after Intravitreal tissue plasminogen activator (tPA) and pneumatic displacement of submacular haemorrhage. Am J Ophthalmol 2000;129:546-47. [ PUBMED] [ FULLTEXT] |
| 7. | Ohji M, Saito Y, Hayashi A, Lewis J M, Tano Y. Pneumatic displacement of subretinal haemorrhage without tissue plasminogen activator. Arch Ophthalmol 1998;116:1326-32. |
| 8. | Daneshvar H, Kertes PJ, Leonard BC, Peyman GA. Management of submacular haemorrhage with Intravitreal sulphur hexafluoride: A pilot study. Can J Ophthalmol 1999;34:385- 88. [ PUBMED] |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
| This article has been cited by | | 1 |
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| Lincoff, H., Kreissig, I., Stopa, M., Uram, D. | | Retina. 2008; 28(1): 56-59 | | [Pubmed] | | | 2 |
Pneumatic displacement of submacular hemorrhage: Safety, efficacy, and patient selection |
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| Gopalakrishan, M., Giridhar, A., Bhat, S., Saikumar, S.J., Elias, A., N, S. | | Retina. 2007; 27(3): 329-334 | | [Pubmed] | |
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