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Intravitreal Recombinant Tissue Plasminogen Activator Without Gas Injection in a Patient with Massive Submacular Hemorrhage Associated with Age-Related Macular Degeneration: A Case Report

Hiroyuki Kamao, Masaki Nakagawa, Naoki Okamoto and Junichi Kiryu

Introduction: Submacular hemorrhage (SMH) is a leading cause of severe visual loss. Pneumatic displacement of SMH from the macular area using intravitreal injection of tissue plasminogen activator (tPA) and gas and vitrectomy with subretinal injection of tPA and intravitreal injection of gas have recently been used as the standard therapies for SMH patients. However, little has been reported on single intravitreal administration of tPA for SMH patients.
Case report: A 62-year-old male patient noted both blurred vision in his left eye and difficulty speaking (dysarthria) 1 day before admission. He was diagnosed with both massive SMH and cerebral infarction. Funduscopy revealed that the fovea was shifted to the inferonasal side due to a massive subretinal blood clot, and optical coherence tomography (OCT) revealed steep retinal detachment, hyper-reflective material representing a blood clot under the retina, and multiple large retinal pigment epithelial detachments (PEDs). The patient received a single intravitreal administration of tissue plasminogen activator. After vitreous injection, nearly all of the massive subretinal blood clot moved to the peripheral retina, and the fovea returned to the appropriate position. His best corrected visual acuity improved from 20/250 to 20/100.
Conclusion: The present study showed a favorable outcome of a patient with a massive SMH complicated by cerebral infarction after receiving a single intravitreal administration of tPA. We hope that the single intravitreal administration of tPA can be applied for SMH patients who are not appropriate for surgery.