Visual Outcome after Vitrectomy with Subretinal tPA Injection to Treat Submacular Hemorrhage Secondary to Age-Related Macular Degeneration or Macroaneurysm

Purpose. To determine the efficacy and safety of 23G transconjunctival sutureless vitrectomy, subretinal injection of tissue plasminogen activator using the EVA Surgical System, and pneumatic displacement with air to treat submacular hemorrhages. Methods. Retrospective analysis of 93 eyes surgically treated for submacular hemorrhage caused by neovascular AMD or retinal macroaneurysms. Main Outcome Measures. Postoperative visual acuity and surgical complications. Results. After surgery, visual acuity improved after 6 weeks but decreased again at the final postoperative visit at 8 months due to progression of the underlying disease. Complications consisted of 2 cases of retinal pigment epithelial tear, 7 vitreous hemorrhages, 4 hyphema, 6 cases of retinal detachment, and 2 subchoroidal hemorrhages during the follow-up period. Conclusions. This study suggests that a surgical approach with 23G vitrectomy, subretinal tPA injection, and pneumatic displacement using air may be an effective procedure for submacular hemorrhage displacement in patients with AMD and retinal macroaneurysms. However, visual outcome is limited by the underlying macular pathology. Larger multicenter randomized controlled studies are warranted to determine the therapeutic effect of this surgical approach.

Retinal Hemorrhage after SARS-CoV-2 Vaccination

To report retinal vein occlusion (RVO) and age-related macular degeneration (AMD)-related submacular hemorrhage developing after administration of SARS-CoV-2 vaccines, a single-center, retrospective observational case series was conducted. Clinical data including fundus photographs and optical coherence tomography (OCT) scans were reviewed. Twenty-three eyes of 21 patients were included with the median age at symptom presentation being 77 years (range: 51–85 years). Twelve eyes (52.2%) had submacular hemorrhage and 11 (47.8%) had RVO. Twelve patients (60.9%) had been vaccinated with the Pfizer vaccine (BNT162b2) and 8 with the AstraZeneca (ChAdOx1) vaccine. Sixteen patients (76.2%) experienced ocular disease exacerbation after the first vaccination and 4 (19.0%) after the second vaccination. The median visual acuity (logarithm of the minimal angle of resolution; logMAR) before symptom development was 0.76 (interquartile range: 0.27–1.23); the median logMAR at symptom presentation was 1.40 (interquartile range 0.52–1.70). The median time between vaccination and symptom exacerbation was 2.0 days (interquartile range: 1.0–3.0 days). Five patients (23.8%) underwent tests for hematological abnormalities, including the presence of anti-PF4 antibodies; all were negative. Further studies with larger patient group for evaluation of effect of SARS-CoV-2 vaccination on retinal hemorrhage are necessary.

Suprachoroidal Gas: A Rare Complication of Intravitreal Injection of Perfluoropropane

This is a case report of a 75-year-old pseudophakic male, who presented with a massive submacular hemorrhage on a background of neovascular age-related macular degeneration. Intravitreal perfluoropropane was used to attempt pneumatic displacement of the submacular hemorrhage. The next day, subconjunctival gas was observed, with no gas seen in the vitreous cavity. Fundal examination showed suprachoroidal detachment. CT images confirmed gas entrapment, with no choroidal hemorrhage identified. The following case report describes suprachoroidal gas as a complication of intravitreal injection of perfluoropropane for pneumatic displacement of submacular hemorrhage. To our knowledge, this is the first such case in the literature. We describe the approach in differentiating suprachoroidal gas from hemorrhage and comment on a plausible mechanism for this complication. This report also serves as a review of the current state of knowledge in the area of suprachoroidal gas as a complication of pneumatic retinopexy and sutureless vitrectomy.

Tissue Plasminogen Activator Toxicity after Submacular Hemorrhage Repair

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Assessment of morphological and functional results of treatment of patients with subfoveal hemorrhage secondary to AMD

Purpose. The aim of the study was to evaluate the morphological and functional parameters of the retina after subretinal administration of recombinant prourokinase followed by pneumodislocation in comparison with anti-VEGF (Vascular endothelial growth factor) monotherapy in the long term in patients with subfoveal hemorrhage. Material and methods. Depending on the choice of surgical treatment, the patients were divided into two groups: Group 1 – 11 patients (11 eyes) – patients receiving anti-VEGF therapy as the main treatment according to the treat and extend regimen; Group 2 – 9 patients (9 eyes) – patients who underwent translocation of submacular hemorrhage followed by intravitreal administration of anti-VEGF drugs according to the treat and extend regimen. Results. Elimination of the clot to the peripheral regions made it possible to achieve an improvement in the architectonics of the retina in the central zone, in particular, a decrease in the central thickness of the retina in the group with subretinal administration of tissue plasminogen activator by an average of 654.67 µm after 3 months. According to a comparative analysis of morphological parameters at the end of the observation period, in the 2nd group, the decrease in central foveal thickness exceeded the data shown in the 1st group by 16 times. Analysis of the height of choroidal neovascularization showed a depression of the final results 4.34 times relative to the initial values in the combined treatment group. Positive dynamics persisted throughout the entire period of treatment against the background of ongoing anti-vasoproliferative therapy. Conclusion. The technique of subretinal injection of recombinant prourokinase followed by tamponade with an air mixture used in the study demonstrates an increase in visual functions against the background of a favorable anatomical outcome. Key words: submacular hemorrhage, tissue plasminogen activator, pneumodislocation.

Principles of therapy for subretinal hemorrhage

Purpose. To study approaches to the treatment of submacular hemorrhage in age-related macular degeneration based on the literature data. Material and methods. The search for publications on the treatment of submacular hemorrhage (SMH) was carried out in the PubMed, SCOPUS, Umedp databases, as well as manually in journals and publications of conference materials until January 2021. Results and discussion. SMH treatment is represented by a variety of methods, from minimally invasive methods, such as intravitreal injection of drugs, gas tamponade and their combinations, to complex surgical approaches with pigment epithelium transplantation. Conclusions. The successful treatment of massive SMH is possible with minimally invasive methods. However, with significant prominating SMH, vitreoretinal surgical interventions are more appropriate. It is advisable to treat SMH as soon as possible from the moment of hemorrhage. Key words: submacular hemorrhage, age-related macular degeneration, pneumodislocation, vitrectomy, anti-VEGF inhibitors, tissue plasminogen activator.