Subretinal tPA + Air for Massive Submacular Hemorrhage

A 76-year-old woman was referred for Count Fingers vision in the left eye of approximately 2-week duration due to a massive submacular hemorrhage from neovascular macular degeneration. Intravitreal bevacizumab was injected in the office, and vitrectomy surgery with subretinal tissue plasminogen activator plus air was scheduled for two days later. Adding subretinal air can assist in inferior displacement of the thick hemorrhage, and a thorough shave of the inferior vitreous base as well as scleral depression to check for any inferior retinal breaks is important. Surgery should ideally be done within 7 days of hemorrhage onset to maximize displacement. Following a partial fluid–gas exchange with SF6 20%, the patient was instructed to be supine for 1 hour after surgery and then upright with downgaze positioning for 5 days after surgery. Her vision improved to 20/400 at 2 weeks after surgery with the majority of the hemorrhage displaced into the inferior retinal periphery.

Financial Disclosures: Dr. Enchun Liu discloses no financial relationships.