First Author: M.García SPAIN
Co Author(s): 0 0 0 0 0 0 0 0 0
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Report the case of a patient with a submacular hemorrhage due to wet age macular degeneration treated with a combination of pars plana vitrectomy (PPV), air-fluid exchange and a subretinal injection of tissue plasminogen activator (tPA) and bevacizumab.
The left eye of our patient had been treated with seven ranibizumab and two bevacizumab intravitreal injections before the onset of the hemorrhage. When the patient came to our clinic his visual acuity had dropped from 20/25 to 20/50 and showed a 5 disc diameters hemorrhage affecting the fovea.
The diagnosis of submacular hemorrhage was done after having performed the following evaluations: funduscopy, retinography, optical coherence tomography (OCT) and fluorescein angiography. A PPV with air-fluid exchange and a subretinal injection of tPA (at a concentration of 25 microns in 0.1ml) and bevacizumab was performed. The injection was conducted with a 38 gauge needle. A bullous retinal detachment encompassing the entire blood clot was created. Then was the eye filled with sulfur hexafluoride (SF6) at a concentration of 10%. The patient was instructed to maintain a prone position for 48 hours. Postsurgical examinations included best corrected visual acuity (BCVA), funduscopy, retinography and OCT.
Surgery successfully displaced the hemorrhage from the fovea. One month after surgery the fovea was free from blood and a subretinal fibrotic scar could be seen temporal to the macula. One month after surgery BCVA had raised from 20/50 to 20/40. The OCT obtained prior to surgery showed a subretinal hemorrhage with a central foveal thickness of 489 microns, while in the obtained 1 month after surgery, central thickness had reduced to 190 microns.
Even though no consensus exists as to the single best approach to use in cases of submacular hemorrhage, a combination of PPV, air-fluid exchange and a subretinal injection of tPA and bevacizumab is an effective therapeutic option for recent submacular hemorrhage. It produces a quick liquefaction of the fibrin clot and a displacement of the clot away from the fovea. This stops the mechanical damage of the photoreceptors and the toxic effects that the iron and the hemosiderine produce. It must be taken into consideration that the natural course of untreated hemorrhages often leads to significant permanent visual loss.