A novel technique for extensive submacular hemorrhage using high‑dose tissue plasminogen activator

Background: Submacular hemorrhage (SMH) is a sight‑threatening disorder. Choroidal neovascularization secondary to age‑related
macular degeneration, polypoidal choroidal vasculopathy, trauma, angioid streaks, and pathological myopia are a few important
causes. The conventional treatment of massive SMH is vitrectomy with manual removal of the clot with extensive retinectomy
with/without tissue plasminogen activator (tPA). The usual dose of subretinal tPA is 10-25 μg.[1,2]
Purpose: To describe a new surgical
approach in a case of massive SMH with retinal detachment without retinectomy.
Synopsis: In our case of near total hemorrhagic
retinal detachment due to subretinal hemorrhage caused by trauma (road traffic accident), the patient presented with a visual acuity of
counting fingers. Core vitrectomy was performed and posterior vitreous detachment was induced. The locations for retinotomy to inject
and aspirate subretinal blood were selected at the maximum height of retinal elevation near the arcades. Recombinant tPA (10 μg/0.1 ml
concentration; 0.3 ml injected in two locations) was injected subretinally with a 23‑G soft tip cannula in the superotemporal and
inferonasal quadrant causing subretinal bleb formation. Subsequently, the surgeon waited for approximately 20 min on the table for the
liquefaction of the clot. The liquefied blood and tPA were drained with a silicone soft tip. Endolaser was performed at the retinotomy
site and 1000cs silicone oil was injected. No signs of toxicity such as vitritis, vasculitis, or retinal necrosis were noted.
Highlights:
Our unique technique of high‑dose intraoperative subretinal tPA (60 μg) is safe and helpful in rapid clot lysis and recovery of visual
acuity. The patient gained a visual acuity of 20/80 from counting fingers after 1 month of surgery and 20/60 after silicone oil removal.
A high dose of tPA aids in the immediate aspiration of blood from a small retinotomy. A 23‑G soft tip was used instead of a 41‑G
subretinal cannula to inject a large quantity of subretinal tPA

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Superb video Raja! Complete with 10M FU & limitations, well done!😎