Treatment of submacular hemorrhage with low-dose intravitreal tissue plasminogen activator injection and pneumatic displacement

Objective: To investigate the safety and efficacy of low-dose intravitreal tissue plasminogen activator (tPA) and an expansile gas bubble in displacin g submacular hemorrhage in patients with age-related macular degeneration ( ARMD). Patients and Methods: We reviewed retrospectively the medical records of 14 consecutive patients with ARMD from 1 academic center who received low-dos e intravitreal tPA (18-50 mug) and expansile gas (0.3-0.4 mt of perfluoropr opane) for thrombolysis and displacement of submacular hemorrhage. After th e procedure, patients maintained face-down positioning for 1 to 3 days. Main Outcome Measures: Displacement of blood from the fovea, early and fina l visual acuity, and toxicity of tPA. Results: Submacular blood was completely displaced from the fovea in 10 (21 %) of the 14 patients and partially displaced in 3 (21%). In 1 patient, no displacement occurred. Early (<2 months) postoperative visual acuity improv ed by 2 or more lines in 8 patients (57%). With a mean follow-up of 7.7 mon ths, 2 (15%) of 13 patients maintained 2 or more lines of improvement and 6 9% (9 patients) maintained preoperative visual acuity. No clinical evidence of retinal toxicity was seen at this low-dose of tPA. Conclusions: Doses of intravitreal tPA ranging from 18 to 50 <mu>g and an e xpansile gas bubble are safe and effective in displacing submacular hemorrh age in patients with ARMD. Final visual acuity was limited by the underlyin g presence of end-stage ARMD.