Management of submacular hemorrhage with intravitreal sulfur hexafluoride:a pilot study

Background: Some success has been reported with the intravitreal use of tis sue plasminogen activator (tPA) and perfluoropropane gas in the management of large submacular hemorrhages. However, the dosage of tPA that has been u sed (100 mu g) has a narrow margin of safety, and it remains to be shown th at intravitreal tPA can cross the retina and effect subretinal clot lysis. We carried out a pilot study to evaluate the efficacy of intravitreally adm inistered sulfur hexafluoride (SF6) gas alone in the management of large su bmacular hemorrhages secondary to age-related macular degeneration (AMD). Methods: Three patients with large submacular hemorrhages secondary to AMD seen at a university-affiliate teaching hospital in Ottawa were treated wit h an intravitreal injection of 0.6 mt of SF6 gas. They were instructed to a ssume a prone position for 7 to 10 days. The patients were followed 3, 7, 1 4 and 28 days after the procedure and monthly thereafter for at least 6 mon ths. Colour photography and fluorescein and indocyanine green angiography w ere performed immediately before and 2 weeks after the procedure and, there after, at the discretion of the treating ophthalmologist. Results: In all three cases significant inferior displacement of the submac ular blood was observed. Two patients showed an improvement of vision from counting fingers to 20/70 and to 20/200. In one case the submacular blood w as displaced such that laser photocoagulation of a juxtafoveal choroidal ne ovascular membrane became possible. Interpretation: The results suggest that intravitreally administered SF6 al one may have a role in the management of selected cases of neovascular AMD complicated by significant submacular hemorrhage, These results call into q uestion the utility of adjunctive intravitreal tPA in such cases.