SURGICAL-MANAGEMENT OF SUBMACULAR HEMORRHAGE - A SERIES OF 47 CONSECUTIVE CASES

Background: The development of a thick submacular hemorrhage usually c arries a poor visual prognosis. The surgical removal of submacular blo od may improve the otherwise poor outlook in these cases. Subjects and Methods: Forty-seven consecutive patients underwent vitrectomy with s urgical removal of submacular hemorrhage. The patient population consi sted of two consecutive groups. Group 1 (1989 to 1991) included 23 pat ients (20 with age-related macular degeneration [ARMD], one with idiop athic submacular hemorrhage, one with presumed ocular histoplasmosis s yndrome [POHS], and one with angioid streaks) who underwent: mechanica l clot extraction. Group 2 (1991 to 1993) included 24 patients (19 wit h ARMD, two with POHS, two with arterial macroaneurysm, and one with a ngioid streaks) who underwent tissue plasminogen activator-assisted dr ainage of thick submacular hemorrhage. The dose of tissue plasminogen activator ranged from 10 to 40 mu g. All patients had surgery within 7 2 hours of diagnosis. Results: In group 1, the mean size of the submac ular hemorrhage was 11 disc areas (range, 1 to 16 disc areas). Mean fo llow-up was 40 weeks. Mean postoperative visual acuity for eyes with A RMD was 20/200. (Visual acuity improved in six eyes, was stable in sev en eyes, and deteriorated in seven eyes.) All three of the eyes withou t ARMD had visual improvement with a mean postoperative visual acuity of 20/70. Overall, visual acuity stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%) patients. In group 2, the mean size of the submacular hemorrhage was 11 disc areas (range, 3 to 16 di sc areas). Mean follow-up was 24 weeks. Mean postoperative visual acui ty for eyes with ARMD was 20/480 (visual acuity was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes). Four of five eye s without ARMD had visual improvement and one was stable, with a mean postoperative visual acuity of 20/60. Visual acuity stabilized or impr oved in 22 (92%) of 24 patients and decreased in two (8%). The degree of clot lysis was variable. Conclusions: Submacular hemorrhage seconda ry to ARMD has a poor visual prognosis, with or without surgical drain age. The addition of tissue plasminogen activator-assisted clot lysis does not appear to significantly improve the visual outcome following surgery. The determination of whether surgical intervention is appropr iate in these eases requires a prospective, randomized clinical trial.