Surgical management of submacular hemorrhage. A series of 47 consecutive cases
H. E. Ibanez, D. F. Williams, M. A. Thomas, A. J. Ruby, T. A. Meredith, I. Boniuk and M. G. Grand
Retina Consultants, Ltd, St Louis, Mo.
BACKGROUND: The development of a thick submacular hemorrhage usually
carries a poor visual prognosis. The surgical removal of submacular blood
may improve the otherwise poor outlook in these cases. SUBJECTS AND
METHODS: Forty-seven consecutive patients underwent vitrectomy with
surgical removal of submacular hemorrhage. The patient population consisted
of two consecutive groups. Group 1 (1989 to 1991) included 23 patients (20
with age-related macular degeneration [ARMD], one with idiopathic
submacular hemorrhage, one with presumed ocular histoplasmosis syndrome
[POHS], and one with angioid streaks) who underwent mechanical clot
extraction. Group 2 (1991 to 1993) included 24 patients (19 with ARMD, two
with POHS, two with arterial macroaneurysm, and one with angioid streaks)
who underwent tissue plasminogen activator-assisted drainage of thick
submacular hemorrhage. The dose of tissue plasminogen activator ranged from
10 to 40 micrograms. All patients had surgery within 72 hours of diagnosis.
RESULTS: In group 1, the mean size of the submacular hemorrhage was 11 disc
areas (range, 1 to 16 disc areas). Mean follow-up was 40 weeks. Mean
postoperative visual acuity for eyes with ARMD was 20/200. (Visual acuity
improved in six eyes, was stable in seven eyes, and deteriorated in seven
eyes.) All three of the eyes without ARMD had visual improvement with a
mean postoperative visual acuity of 20/70. Overall, visual acuity
stabilized or improved in 13 (57%) of 23 patients and decreased in 10 (43%)
patients. In group 2, the mean size of the submacular hemorrhage was 11
disc areas (range, 3 to 16 disc areas). Mean follow-up was 24 weeks. Mean
postoperative visual acuity for eyes with ARMD was 20/480 (visual acuity
was stable in 15 eyes, improved in two eyes, and deteriorated in two eyes).
Four of five eyes without ARMD had visual improvement and one was stable,
with a mean postoperative visual acuity of 20/60. Visual acuity stabilized
or improved in 22 (92%) of 24 patients and decreased in two (8%). The
degree of clot lysis was variable. CONCLUSIONS: Submacular hemorrhage
secondary to ARMD has a poor visual prognosis, with or without surgical
drainage. The addition of tissue plasminogen activator-assisted clot lysis
does not appear to significantly improve the visual outcome following
surgery. The determination of whether surgical intervention is appropriate
in these cases requires a prospective, randomized clinical trial.
