ACUTE HAEMORRHAGE

Rapid treatment of a submacular haemorrhage is crucial, as progressive retinal damage begins within 24 hours, Elsbeth JT van Zeeburg MD, PhD, of the Rotterdam Eye Hospital, told delegates at the 14th EURETINA Congress in London.

But which treatment is most effective? Dr van Zeeburg described the results of her team’s single-centre, prospective, randomised, controlled study of treatment of acute submacular haemorrhage due to AMD.

Twenty-four patients were randomised to either minimal invasive treatment-intravitreal injections of rtPA plus bevacizumab plus C3F8, or maximal invasive treatment vitrectomy plus subretinal rtPA plus C3F8 gas plus intravitreal bevacizumab. All patients also received intravitreal anti-VEGF treatment at five and 10 weeks thereafter.

“There is a current trend towards vitrectomy with submacular administration of rtPA, as this seems to be a more controlled administration route for surgeons. However, the literature does not yet indicate any difference in safety or efficacy of either method,” she noted.

Intravitreal injection of rtPA with a gas tamponade seems to be a very effective method and can be performed in an office setting. Because no operating theatre is required, it can be planned and performed quickly, minimising the time between the onset of haemorrhage and treatment.

Dr van Zeeburg noted that rtPA administration is also a good treatment option for patients with a submacular haemorrhage due to a retinal macroaneurysm. As these patients do not have underlying macular pathology, the potential visual acuity gain from early haemorrhage displacement in this patient group is significant.

The goal of the current study was to compare the displacement of the subretinal haemorrhage, subretinal fluid and sub-RPE volume away from a 1.0mm3 and a 2.2mm3 cylinder around the macula, as measured on SD-OCT. Because of this quantitative, detailed volumetric analysis, only haemorrhages with a thickness of 750μm or less were included.

“Intravitreal rtPA injection seems as effective in displacing the subretinal haemorrhage and subretinal fluid as vitrectomy with submacular administration,” said Dr van Zeeburg.

Visual acuity results are both favourable and comparable in the two groups. Total displacement of subretinal haemorrhage and fluid occurred in a majority of patients in both groups. However, total displacement of sub-RPE volume was more difficult to achieve, with a relative volume reduction of less than 30 per cent in both groups, but the total volume of this sub-RPE volume is relatively minimal compared to the subretinal volume.

Complications occurred in both groups. Patients in the submacular group suffered retinal detachment (two) and new submacular haemorrhage (one). Those
in the intravitreal group experienced
one retinal detachment, one new submacular haemorrhage, two vitreous haemorrhages and one intraocular pressure spike above 50mmHg within four hours after the injection.

“Increased IOP can be avoided by injecting 0.2ml C3F8 gas the day of the rtPA administration, and an additional 0.2ml the day after,” said Dr van Zeeburg.

“As the results seem comparable, whilst the intravitreal injection is less invasive, simpler to perform and does not require access to an operating theatre, we will soon compare intravitreal rtPA with anti-VEGF agents in a larger, multi-centre controlled trial,” said Dr van Zeeburg.