Comparison of different treatment options in submacular haemorrhage

Abstract

Background/aims: Submacular haemorrhages (SMH) cause significant visual impairment. Until now, the comparative effectiveness of different treatment approaches remains inconclusive without clear treatment guidelines. The aim of our study was to evaluate the effectiveness of 5 surgical treatment modalities in terms of visual prognosis and success rate.

Methods: This retrospective study included 201 patients with SMH. Primary endpoint was best corrected visual acuity (BCVA), secondary endpoints included haemorrhage size and complications. Group 1 was treated with pneumatic displacement and rtPA-injection. Group 2 followed the "Manchester protocol" with rtPA-injection and-if needed-a standardised secondary procedure with pars plana vitrectomy (ppV) and subretinal rtPA. Group 3 underwent vitrectomy with subretinal rtPA, group 4 vitrectomy only and group 5 received subretinal lavage.

Results: Baseline characteristics were a mean age of 79 years and a follow-up of 4.6 months. Pre-intervention BCVA of 1.7 logMAR improved to 1.4 logMAR at follow-up. A gain of > 0.2 logMAR was achieved in 47% of patients, while 20% lost > 0.2 logMAR. Only group 2 achieved a statistically significant visual gain. While group 5 was statistically larger in haemorrhage size preoperatively (p < 0.05), all groups were statistically equal in SMH size at follow-up. Complications led to additional interventions in 20% of patients.

Conclusions: No significant change in visual prognosis could be achieved depending on the intervention. As more invasive techniques seem to lack the benefit of a better postoperative prognosis while carrying higher risks, it may be beneficial considering a less invasive option first.

Keywords: Macular degeneration; Macular haemorrhage; Pars plana vitrectomy; Pneumatic displacement; Recombinant Plasminogen activator; RtPA; Submacular haemorrhage; Subretinal haemorrhage; Subretinal lavage.

Fig. 1

Patients presenting with submacular haemorrhage within 14 days of symptoms onset and treatment initiation other than anti-VEGF only were defined within five subgroups for comparison. Patients with missing data or decision of no treatment were excluded from the study

Fig. 2

The mean absolute visual acuity was compared between the groups. Only those treated with the Manchester protocol achieved a statistically significant difference, improving from 1.6 (± 0.8) to 1.1 (± 0.8) logMAR (p = 0.04). a The resulting absolute BCVA was also higher within the Manchester protocol compared to most of the other groups. c Pre-interventional BCVA was lower in the ppV only group because of a suspected bias due to a significant higher amount of vitreous haemorrhage in this group (*p < 0.05, **p < 0.01) (b)

Fig. 3

46% of the patients across all groups gained > 0.2 logMAR of visual acuity. However, most patients remained unchanged in BCVA (33%) or lost > 0.2 logMAR of visual acuity at follow-up (21%). The proportions varied between the treatment protocols, but did not reach statistical significance (p = 0.2)

Fig. 4

Projected size of haemorrhage measured as optic disc area equivalents on funduscopic images. None of the groups reached statistical significance in the reduction of haemorrhgae size (a). Preoperatively, the haemorrhage size was statistically significantly different between groups. b However, at final follow-up, the size of haemorrhage was statistically equal between all groups (p > 0.05). (*p < 0.05, **p < 0.01) (c)