Tissue Plasminogen Activator Yields Results for Wet AMD-Related Thick Subfoveal Hemorrhage

Vitrectomy plus subretinal injection of tissue plasminogen activator (tPA) reduced scar area moreso than pneumatic displacement plus intravitreal injection of tPA. Visual acuity improved noticeably after both of these treatments, but not after treatment with pneumatic displacement alone.

for acute hemorrhage from a subfoveal choroidal neovascular membrane in patients with exudative age-related macular degeneration (nAMD) indicated that intravitreal injection of tissue plasminogen activator (tPA) enhanced the results of pneumatic displacement treatment.

In a retrospective case series from a single tertiary referral center, a team of investigators analyzed the records of 39 patients with nAMD who were treated for acute subfoveal macular hemorrhage >250 μm within 2 weeks of presentation.

Treatments consisted of the following:

1. Vitrectomy plus subretinal injection of tPA

2. Pneumatic displacement plus intravitreal injection of tPA, or

3. Pneumatic displacement alone.

Treatment groups did not differ in any of the following variables:

  • Age
  • Sex
  • Initial visual acuity
  • Initial area of acute thick subfoveal hemorrhage
  • Lens status
  • Duration of follow-up
  • Duration of nAMD
  • Previous intravitreal bevacizumab (Avastin/Roche) injections
  • Time from last injection given to acute onset of acute thick subfoveal hemorrhage

For each type of treatment, the researchers determined both functional and anatomic outcomes. They determined functional outcome by assessing visual acuity with a Snellen chart and anatomic outcome by measuring the area of the final subretinal disciform scar.

The researchers determined that final Snellen visual acuity improved significantly in both the vitrectomy plus subretinal tPA group (P < 0.001) and the pneumatic displacement plus intravitreal tPA group (P = 0.002). In contrast, visual acuity did not improve to a statistically significant degree in the group treated with pneumatic displacement alone.

Furthermore, in those treated with vitrectomy plus subretinal tPA, the final scar area was reduced by 40% ± 54%, but in those treated with pneumatic displacement plus intravitreal tPA, it was reduced by only 27% ± 35% (P = 0.001).

These findings prompted the researchers to conclude that, in nAMD patients with thick subfoveal hemorrhage from a subfoveal choroidal neovascular membrane, pneumatic displacement plus intravitreal tPA produced better outcomes than pneumatic displacement without tPA. Nevertheless, compared with pneumatic displacement with or without intravitreal tPA, vitrectomy plus subretinal tPA minimized the area of the final subretinal disciform scar.

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