Little effect of tissue plasminogen activator in subretinal surgery for acute hemorrhage in age-related macular degeneration.

We studied the effect of intraoperative fibrinolysis prior to surgical evacuation of subretinal hemorrhage, which has been recommended as a valuable adjunct in the surgical treatment of submacular hemorrhage. We analyzed retrospectively the records of eight patients who underwent pars plana vitrectomy combined with subretinal injection of tissue plasminogen activator (TPA). The duration of symptoms ranged from 2 h to 14 days (median 1.5 days). During vitrectomy, TPA (6-75 micrograms) was injected subretinally through a retinotomy. After 20 min the liquified blood was surgically drained. The residual clot had to be extracted mechanically through an enlarged retinotomy site. In all patients, fibrinolysis was incomplete and an additional mechanical clot extraction was necessary. The postoperative visual acuity improved slightly in four patients, stabilized at the preoperative level in three patients, and worsened in one patient. During follow-up, one patient suffered from retinal detachment. In four patients a cataract developed. In all eyes, large defects of the retinal pigment epithelium resulted. In contrast to other authors, we did not find an acceptable liquefaction of the subretinal clot that would have facilitated surgical extraction of the hemorrhage. Therefore, a therapeutic benefit from the injection of TPA before removal of a subretinal hemorrhage was not distinct.