Treating large submacular hemorrhage through tenecteplase delivery without puncturing the retinal surface: Case series

Purpose To introduce a modified subretinal injection method without retinal puncture for the treatment of large retinal submacular hemorrhage (SMH). Methods Fourteen patients with polypoidal choroidal neovascularization (PCV) complicated with SMH were included in this study. Patients received the non-puncturing subretinal injection of the tissue plasminogen activator tenecteplase (TNK) to dissolve subretinal hemorrhage during pars plana vitrectomy (PPV). Results The injection was successful in all patients without retinal breaks or additional trauma. After the operation, the subretinal hemorrhage in the macular area was absorbed well in 14 patients, which was manifested as the thinning of the central macular thickness and the decrease of the hemorrhage area. During the follow-up period, rhegmatogenous retinal detachment occurred in two patients at one to two months after surgery, which may be due to the formation of holes in the peripheral degeneration area rather than the holes at the injection site; the complicated cataract was developed in three patients at three to six months after surgery, which were improved after phacoemulsification and intraocular lens (Phaco + IOL) implantation. Four patients received intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) after surgery. And two patients experienced recurrent vitreous hemorrhage after surgery. Following vitreous cavity irrigation, the subretinal hemorrhage was reduced compared to its preoperative level, and they are currently recovering well. Conclusions The surgical method of vitrectomy combined with subretinal injection of TNK without retinal puncture can bring benefits to the anatomical and visual outcomes of patients with large SMH and can be considered for further use in patients with large SMH caused by various diseases.