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And Pneumatic Displacement of Submacular Hemorrhage 5. Ross R, Gitter K, Cohen G, Schomaker K. Idiopathic polypoi- subretinal blood through a retinotomy.4 To move the dal choroidal vasculopathy associated with retinal arterial blood out of the central macula without the need for a pars macroaneurysm and hypertensive retinopathy. Retina 1996; plana vitrectomy and retinotomy, Heriot (American 16:105–111. Academy of Ophthalmology Annual Vitreoretinal Update presentations, 1996–1997, unpublished data) reported the use of an intravitreal injection of tissue plasminogen Vitreous Hemorrhage After activator and gas with postoperative face down positioning Intravitreal Tissue Plasminogen to lyse the blood clot and then displace the blood periph- Activator (t-PA) and Pneumatic erally from the submacular space. Intravitreal injection of tissue plasminogen activator and gas was performed in two Displacement of Submacular cases of sudden submacular hemorrhage associated with Hemorrhage retinal arterial macroaneurysm. Dense vitreous hemor- Gregg T. Kokame, MD rhage was noted after intravitreal injection of tissue plas- minogen activator and intraocular gas. PURPOSE: To report the immediate complication of dense ● vitreous hemorrhage after intravitreal injection of tissue CASE 1: A 92-year-old man developed sudden vision plasminogen activator and gas for treatment of two cases loss in his left pseudophakic eye for 1 day before of sudden submacular hemorrhage associated with retinal presentation. His visual acuity was RE: 20/20, LE: arterial macroaneurysm. 20/400. A thick subfoveal hemorrhage and subinternal METHODS: Case reports. limiting membrane hemorrhage in the central macula RESULTS: Two patients, a 67-year-old woman and a were noted. Two days after symptom onset, an intra- ␮ 92-year-old man, presented with sudden vision loss vitreal 50- g injection of tissue plasminogen activator related to submacular hemorrhage from a retinal macro- and 0.55 ml of sulfur hexafluoride (SF6) gas were given aneurysm. Tissue plasminogen activator at a dose of 50 under retrobulbar anesthesia. On the first postoperative ␮ ␮ day, a dense vitreous hemorrhage with decreased vision gto75 g and a sulfur hexafluoride (SF6) gas bubble were injected intravitreally under local anesthesia. Dense to hand motion was noted. Intermittent face down vitreous hemorrhage was noted on the first postoperative positioning was continued for 5 days. Echography day in both cases, which subsequently required pars showed dense vitreous hemorrhage and inferotemporal plana vitrectomy removal. displacement of the submacular hemorrhage. Six weeks CONCLUSION: Sudden severe vitreous hemorrhage may be postoperatively, pars plana vitrectomy was performed. an immediate complication after intravitreal injection of Findings showed a microscopic hyphema, dense brown tissue plasminogen activator and gas for treatment of vitreous blood, thin residual submacular hemorrhage, an submacular hemorrhage associated with retinal arterial inferotemporal retinal macroaneurysm, and displaced macroaneurysm. (Am J Ophthalmol 2000;129: subretinal blood in the inferior midperiphery. Three 546–547. © 2000 by Elsevier Science Inc. All rights months later, visual acuity had improved to 20/80, with reserved.) resolution of submacular hemorrhage. ● CASE 2: A 67-year-old woman developed sudden loss of UBMACULAR HEMORRHAGE CAUSES SUDDEN VISION vision in the left eye for 3 days before presentation. Her loss and can be associated with a variety of causes, the S visual acuity was RE: 20/20, LE: 2/200. A thick subfoveal most common being age-related macular degeneration, hemorrhage and subinternal limiting membrane hemor- retinal arterial macroaneurysm, and trauma. When the rhage in the central macula were noted. Four days after submacular hemorrhage is thick, the visual prognosis is symptom onset, an intravitreal injection of 75 ␮g of tissue poor.1 Because of this, tissue plasminogen activator, a plasminogen activator and 0.5 ml of sulfur hexafluoride fibrin-specific protease, has been used as an adjunct in (SF ) gas were given. On the first postoperative day, a subretinal injections during vitrectomy to lyse the subreti- 6 dense vitreous hemorrhage with decrease in vision to hand nal clot and facilitate surgical drainage.2,3 Intravitreal motion was noted. Echography showed severe vitreous injections of tissue plasminogen activator have also been opacities, decreased submacular hemorrhage, and infero- given 1 day before vitrectomy and surgical removal of temporal displaced subretinal hemorrhage. Intermittent face down positioning was continued for 5 days. Two Accepted for publication Nov 29, 1999. From the Division of Ophthalmology, Department of Surgery, Univer- months postoperatively, a pars plana vitrectomy was per- sity of Hawaii School of Medicine, Honolulu, Hawaii, and the Retina formed. Findings revealed dense brown vitreous hemor- Center at Pali Momi, KapiЈolani Health, Aiea, Hawaii. rhage, focal superonasal submacular hemorrhage, a superior Inquiries to Gregg T. Kokame, MD, The Retina Center at Pali Momi, 98-1079 Moanalua Rd, Ste 470, Aiea, Hawaii 96701; fax: (808) 487- macular macroaneurysm, and displaced inferotemporal 3699. subretinal hemorrhage. One month following vitrectomy, 546 AMERICAN JOURNAL OF OPHTHALMOLOGY APRIL 2000 increased edema and exudate were noted around the 5. Kamei M, Misono K, Lewis H. A study of the ability of tissue macroaneurysm. Focal laser treatment to the macroaneu- plasminogen activator to diffuse into the subretinal space after rysm was placed. Three months following vitrectomy, intravitreal injection in rabbits. Am J Ophthalmol 1999;128: 739–746. visual acuity was 20/200, without residual submacular hemorrhage or active leakage. Sudden and severe vitreous hemorrhage may be an immediate complication of intravitreal injection of Improvement in Macular Function tissue plasminogen activator and gas for treatment of After Retinal Translocation Surgery submacular hemorrhage associated with retinal macro- in a Patient With Age-Related aneurysm. Although the ability of intravitreal tissue Macular Degeneration plasminogen activator to penetrate through the internal limiting membrane and into the subretinal space is Michael J. Potter, MD, Tom S. Chang, MD, controversial, these cases suggest that tissue plasmino- Ann S. Lee, BSc, and Sushma Rai, MD gen activator can penetrate the internal limiting mem- brane to the level of the arterial macroaneurysm. Recent PURPOSE: To assess focal electroretinographic findings experimental work in the rabbit, which does not have a before and after retinal translocation surgery in a patient foveal region and thinner internal limiting membrane in with age-related macular degeneration. the fovea as the human, shows that molecules as large as METHOD: Case report. A 79-year-old man with a well- tissue plasminogen activator (70 kD) injected into the defined subfoveal choroidal neovascular membrane from vitreous cavity do not penetrate the internal limiting age-related macular degeneration underwent preopera- membrane or into the subretinal space.5 Although tive and postoperative focal electroretinography. severe vitreous hemorrhage was not noted before tissue RESULTS: After retinal translocation surgery, best-cor- plasminogen activator injection in these cases with rected Snellen visual acuity improved from 9/200 to retinal macroaneurysm, subinternal limiting membrane 20/60. A significant increase in mean foveal amplitude, .was recorded (0.008 ؍ hemorrhage was noted in both cases. Subinternal limit- from 0.08 ␮V to 0.16 ␮V(P ing membrane hemorrhage could allow increased in- CONCLUSION: Age-related macular degenerative changes traretinal penetration of intravitreal tissue plasminogen in visual acuity and foveal electroretinogram amplitude activator through focal breaks and displacement of the may be reversible after retinal translocation surgery. internal limiting membrane and predispose these eyes to (Am J Ophthalmol 2000;129:547–549. © 2000 by the potential complication of increased bleeding from Elsevier Science Inc. All rights reserved.) the retinal macroaneurysm. Alternatively, vitreous bleeding could have occurred from the pars plana GE-RELATED MACULAR DEGENERATION IS THE LEAD- injection sites, but this immediate complication was not Aing cause of legal blindness in older people in the noted in other series of intravitreal injections of tissue Western world. A recent development in the treatment of plasminogen activator and gas (Heriot WJ, American age-related macular degeneration is retinal translocation, Academy of Ophthalmology Annual Vitreoretinal Up- whereby the fovea is surgically moved a short distance date presentations, 1996–1997, unpublished data).4 away from an underlying choroidal neovascular lesion.1 This complication was also not noted during subretinal Only a few cases have been reported, and long-term injections of up to 50 ␮g of tissue plasminogen activator outcomes are unknown. A key issue in evaluating this new during vitreous surgery for submacular hemorrhage as- procedure is the measurement of macular function before sociated with retinal arterial macroaneurysms.3 and after surgery. We present a case of age-related macular degeneration with successful translocation surgery, in REFERENCES which focal electroretinography was used as an objective measurement of improvement in macular function. 1. Bennett SR, Folk JC, Blodi CF, Klugman F. Factors prognostic A 79-year-old man presented with a central scotoma of visual outcome in patients with subretinal hemorrhage. Am J Ophthalmol 1990;109:33–37.
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