Immediate Surgery Combined with Injections for Submacular Bleeding May be Most Effective for Restoring Vision
The Mount Sinai Health System in New York announced the publication of a paper titled “Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage” in the British Journal of Ophthalmology.
A summary of the study, which can be found in its entirety here, is outlined below.
Title: “Outcomes of pars plana vitrectomy with subretinal tissue plasminogen activator injection and pneumatic displacement of fovea-involving submacular haemorrhage”
Authors: Carl Wilkins, MD, Chief Resident in the Department of Ophthalmology at the Icahn School of Medicine at Mount Sinai
Richard Rosen, MD, Deputy Chair of Ophthalmology and Director of Research at New York Eye and Ear Infirmary of Mount Sinai
Bottom Line: Submacular surgery combined with the stroke treatment tPA (tissue plasminogen activator) can lead to significant vision improvement in patients with submacular bleeding. Conservative medical therapy (anti-VEGF injections), which is considered the standard of care, can often fall short of restoring vision. Mount Sinai researchers looked at the effectiveness of submacular surgery in dissolving the blood clot and found significant vision improvement in almost half of the analyzed patients (three or more lines on the eye chart), and more than half experienced some improvement.
What does this research show? It suggests that all patients should be considered for this type of intervention soon after the event occurs. There is a brief window of opportunity for restoration of vision in these cases—only about 2 weeks. After that, improvement is much less likely. Conservative management may be doing the patient a disservice.
Why this research is interesting: It confirms results reported by many smaller studies and contradicts conclusions from an earlier study by the National Eye Institute on subretinal surgery, which recommended conservative care. That study was conducted 20 years ago, well before modern advances in surgical vitrectomy.
How the research was conducted: Researchers performed a retrospective chart review of all patients who had the surgical vitrectomy with tPA medication at New York Eye and Ear Infirmary of Mount Sinai (NYEE). This helped identify these uncommon but notable cases, from the large volume of retinal surgeries performed at NYEE.
Conclusions: The median visual acuity of patients in the analysis was “counting fingers” before surgery, and 20/150 after, however some improved substantially more. Many of them had poorer baseline vision due to the underlying causes of their bleeding. Patients recovered a similar proportion of vision, regardless of the underlying cause of their submacular hemorrhage, and had a similar adverse event rate to other academic centers who have used and reported on this technique (tPA plus surgery).
What this means for practitioners: If patients have moderate to severe vision loss from submacular hemorrhage, ophthalmologists should consider them as a surgical candidate early on, regardless of the underlying cause of the bleeding. Since each patient is different, doctors must consider risks of surgery, including anesthesia, access to this intervention, and how acute the problem is. This approach avoids the necessity for head-down positioning post-operatively, which may make it easier for patients with compliance issues due to age, balance, or musculoskeletal issues.
How this can help patients: Patients with significant vision loss from this condition may consider surgical intervention on a case-by-case basis, as it offers visual recovery for a diverse group of patients.