Effects of Neodymium:YAG Laser and Tissue Plasminogen Activator on Massive Diabetic Premacular Hemorrhage

PURPOSE: To investigate the combined therapeutic effects of Neodymium:YAG (Nd:YAG) laser membranotomy and intravitreal tissue plasminogen activator (tPA) on massive diabetic premacular hemorrhage. METHODS: The authors performed Nd:YAG laser membranotomy on the hemorrhagic membrane of premacular hemorrhages and injected tPA (25 microgram) into the vitreous cavity of 5 eyes with massive diabetic premacular hemorrhage. Each time, 0.2 ml of perfluoropropane (C3F8) gas was also injected. RESULTS: After Nd:YAG laser membranotomy and tPA injection, the patients' vision recovered within 4 weeks and the hemorrhages were completely absorbed within 8 weeks. Visual acuity at the last visit had improved to a mean of 10 lines (8-13 lines) on ETDRS charts for all cases. There were no associated ophthalmic complications. Also, there were no cases that required vitrectomy. CONCLUSIONS: Combined therapy of Nd:YAG laser membranotomy and tPA injection with an expansive gas is a good alternative method to observation or simple Nd:YAG laser treatment for resolution of premacular hemorrhages in proliferative diabetic retinopathy patients, and may allow for faster resolution of hemorrhages without the complications of vitrectomy.

The Effect of Tissue Plasminogen Activator on Premacular Hemorrhage

Early vitrectomy is recommended for eyes with premacular hemorrhage, which facilitates fibrovascular proliferation and macular traction. To assess the effect of tissue plasminogen activator(tPA)on the absorption of premacular hemorrhage, we injected tPA(25 microgram)into the vitreous cavity of 13 eyes with premacular hemorrhage and followed for 30 days. We classified the type of hemorrhage according to the site of hemorrhage and the presence of posterior vitreous detachment(PVD). Four eyes had complete PVD following vitrectomy, 4 eyes had a hemorrhage in the subhyaloid space and 5 eyes had a hemorrhage in the subinternal limiting membrane. The mean absorption time of hemorrhage after tPA injection was 5. 5 days in 4 eyes of complete PVD and 12. 7 days in the remaining types. Visual acuity improved in 9 eyes, remained stable in 3 eyes and worsened in 1 eyes following tPA injection. Five eyes required pars plana vitrectomy due to recurrent vitreous hemorrhage and macular traction. TPA seemed to be considered another method of treatment in the eyes of premacular hemorrhage, especially in the vitrectomized eyes or eyes with complete PVD.

Photodisruption of Premacular Hemorrhage with Nd: YAG Laser

Premacular hemorrhage (preretinal,subhyaloid, or sub-internal limiting membrane hemorrhage)impairs central vision abruptly and occurs in various underlying diseases. In cases of persistent hemorrhage, permanent impairment of vision may occur. Proposed therapeutic options for premacular hemorrhage consist of conservative treatment, laser photodisruption and early vitrectomy. Laser photodisruption may be performed in cases of persistent or slow-clearing hemorrhage, in patients with occupational need for prompt restoration of binocular vision or in patients with poor vision in their fellow eyes. The authors report 4 patients with premacular hemorrhage who were treated with Nd: YAG laser photodisruption with the review of the literatures.

A Case of Premacular Hemorrhage Treated by Q-switched Nd:YAG Laser Puncture

Preretinal hemorrhage, which is located between the retina and vitreous face and is commonly developed on the macula, causes impaired central vision and if it persists, it may cause complications, such as epimacular membrane. A 49-year-old male who had dry type of age-related macular degeneration in both eyes and had an oval shaped premacular hemorrhage of unknown etiology in his left eye. We applied Q-switched Nd:YAG laser on membrane anterior to preretinal hemorrhage and ruptured it. Preretinal hemorrage was drained to inferior vitreous cavity and his central vision was rapidly improved.