Subretinal macular blood displacement with snowman technique

Poster Details

First Author: D.Ruiz Casas SPAIN

Co Author(s):    F. Peralta Iturburu   B. Gonzalo Suarez                          

Abstract Details


We present a modified subretinal recombinant tissue plasminogen activator (rtPA) injection to improve submacular blood displacement in submacular bleedings.


Hospital Ramón y Cajal


In this technique we perform a 25G pars plana vitrectomy. Afterwards we prepare a 4 ml solution of recombinant tissue plasminogen activator (rt-PA), balanced-salted solution (BSS) and bevacizumab (1ml of 100 micrograms/ml of rtpa, 2.5 ml of BSS and 0.5 ml of bevacizumab (1,5mg/0.05ml)) and this mixture is put inside the VFI syringe of the vitrectomy device connected to a 25/38G subretinal injection cannula. The VFI is set in the vitrectomy device between 12 and 16 psi. We reduce IOP to 6-8 mmHg and inject the rtpa mixture in the lower part of the macular bleeding. Then we inject again the rtpa mixture below the lower arcade to create and inferior and smaller subretinal bubble in order to direct and improve macula blood displacement to the lower retina. Finally we perform a fluid-air exchange (FAX) in joining both bubbles by pneumatic pressure and a gentle retinal massage with the vitreous cutter and then an air-SF6 20% Exchange. The two bubbles when they join look like a snowman. After surgery the patient is positioned 2 hours in a supine position and afterwards in upright looking slightly down during the day and sleeping with the head elevated at 45º for three days.


The day after surgery most blood is displaced to the inferior part of the retina where a subretinal rtPA and blood bubble is observed which reabsorbs by itself in 1-2 days leaving the inferior retina with a thin subretinal blood layer which is reabsorbed in 1-3 months. With this technique we have seen improvement of visual acuity (VA) from hand motion to 20/50 in our cases.


This technique is pretty similar to previous subretinal blood displacement technique but it improves subretinal blood displacement because the big macular bubble creates a jet of pressure on the inferior smaller bubble that washes out subretinal macular blood when the patient is put in an upright position. Besides it allows the surgeon to direct the macular blood to the inferior retina better avoiding the extension of blood to temporal healthy retina and rpe areas.

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