Comparative analysis of anatomy and fibrosis formation between vitrectomy and vitrectomy combined with intravitreal rt-PA injection into the subretinal macular space for submacular haemorrhage

doi:10.21203/rs.3.rs-3943737/v1

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Comparative analysis of anatomy and fibrosis formation between vitrectomy and vitrectomy combined with intravitreal rt-PA injection into the subretinal macular space for submacular haemorrhage

https://doi.org/10.21203/rs.3.rs-3943737/v1

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Background/Objectives:

To compare the effects of vitrectomy alone and vitrectomy combined with subretinal injection of recombinant tissue plasminogen activator (rt-PA) for submacular haemorrhage(SMH).

Subjects/Methods:

In this retrospective study, 52 patients were diagnosed with SMH, of whom 43 were identified as having polypoidal choroidal vasculopathy (PCV). 19 patients underwent vitrectomy with intravitreal rt-PA injection into the submacular space, and 33 underwent only vitrectomy. Best visual acuity was recorded preoperatively, as well as at 1 week, 1 month, and 3 months postoperatively. Using the Heidelberg optical coherence tomography (OCT) follow-up model, the areas and heights of pigment epithelial detachment (PED), areas of retinal fluid (RF), and central macular thickness (CMT) were measured. Retinal fibrosis within the vascular arcade was evaluated using Optos during follow-up.

Results

One week postoperatively, the combined group started showing a significant decrease in the PED area, height, CMT and RF, with notable improvements in visual acuity at 1 month, whereas in the vitrectomy-only group, PED area significantly decreased after 1 week, along with a significant reduction in the visual acuity in the first month, but a subsequent increase in the third month. CMT only showed significantly reduction at 1week. In the combined group, two patients developed scars within the vascular arcade in the posterior pole during follow-up, whereas in the vitrectomy-only group, this occurred in 13 patients.

Conclusion

Vitrectomy with rt-PA injection into the submacular space demonstrates effectiveness and safety for treating SMH, as well as good prevention of scarring.

Health sciences/Diseases/Eye diseases/Retinal diseases

Health sciences/Medical research/Outcomes research

Submacular haemorrhage

Pigment epithelial detachment

Rt-PA

Optical coherence tomography

Subretinal haemorrhage presents a challenging scenario with potential complications, including the risk of retinal detachment and irreversible vision damage, particularly in individuals diagnosed with age-related macular degeneration (AMD), notably those with polypoidal choroidal vasculopathy (PCV). Despite regular anti-VEGF injections, macular injuries persist, and these interventions do not entirely prevent the progression of macular atrophy, leading to sustained vision decline. Recombinant tissue plasminogen activator (rt-PA), a thrombolytic agent dissolving fibrinogen emerges as a potential solution. In the aftermath of bleeding, fibrinogen deposits between photosensitive cells, and direct contact with rt-PA triggers a more rapid response(1). Existing studies suggest that vitreous injection of rt-PA may not effectively diffuse rt-PA into the retina and displace subretinal haemorrhage. Notably Schulze et al (2) demonstrated limited efficacy of vitreous injections of rt-PA and SF6 in treating submacular haemorrhage (SMH) exceeding 5 mm in diameter. In contrast, subretinal rt-PA injection, owing to its larger molecular size than retinal pores, has proven to be effective (3, 4).

However, the use of subretinal rt-PA injection, while resolving haemorrhage, introduces significant intraoperative and postoperative risks, such as the potential for new bleeding, retinal tears, and intraocular infections. Furthermore, the efficacy of combined subretinal rt-PA injecting in improving vision remains uncertain. Therefore, this study aims to evaluate the risks and benefits associate with subretinal rt-PA injections in patients diagnosed with macular haemorrhage.

Research Population

The study protocol was approved by the Ethics Committee of the Eye Hospital of Wenzhou Medical University and adhered to the principles outlined in the Declaration of Helsinki. This retrospective case series, conducted at the Hangzhou branch of Wenzhou Medical University Affiliated Eye and Optometry Hospital from Nov 2019 to May 2023 included 52 patients who provided informed consent, we can see obvious sub-macular haemorrhages on fundus photographs in all the patients. The diagnostic criteria for PCV were reddish-orange polypoidal lesion visible on OCT and ICGA-visible branching neovascular network (5).

Procedure

Prior to surgery, routine assessments, including slit-lamp fundoscopy, spectral domain optical coherence tomography (SD-OCT) (SPECTRALIS HRA OCT; Heidelberg Engineering, Heidelberg, Germany), and colour fundus photography, were conducted. Among the patients, 19 underwent 25G three-port pars plana vitrectomy (PPV) combined with intravitreal rt-PA injection via a 41G needle at the highest retinal elevation. Twelve of them also underwent combined phaco-emulsification cataract extraction and intraocular lens implantation, while one had prior cataract surgery already; additionally, 33 patients underwent PPV only, with 20 undergoing combined phaco-emulsification cataract extraction and intraocular lens implantation, and two having undergone prior cataract surgeries. Experienced surgeons assessed the necessity for tamponade or inert gas injection. Postoperatively, patient positioning was determined individually at the first week, the first month, and the third month postoperatively, fundus photographs and OCT were performed in all patients. Experienced physicians would assess the patients' need for subsequent anti-VEGF therapy based on visual acuity and examination findings.

Measurement

Visual acuity was logarithmically transformed using logMAR, where counting fingers equated to logMAR 2.0, hand motion to logMAR 2.3, light perception to logMAR 2.6, and no light perception to logMAR 2.9 (6, 7). In the macular area, OCT measurements including the maximum cross-sectional area of pigment epithelial detachment (PED) and retinal fluid (RF) by the built-in software were taken three times and averaged at every visit, as well as the greatest height of PED and central macular thickness (CMT), if the maximum height exceeded the OCT shot, the maximum area displayed in the graph was measured (Fig. 1). Record the presence time or absence of intravascular arch retinal fibrosis at the last follow-up visit, the retinal fibrous scarring was defined as a white or yellow tissue on fundus photographs, which appeared as a dense material in OCT cross section (8).

Statistical Analysis

Statistical analyses were conducted using SPSS 26.0 (version 26.0; SPSS, Inc, Chicago, IL, USA), with significance set at p ≤ 0.05. The chi-square test and Student's t-test were employed to explore differences in proportions and means for categorical and continuous variables, respectively. For non-parametric data, Wilcoxon scores (Kruskal-Wallis test) were used. Generalised estimating equations (gee) were applied to investigate comparative data between multiple groups and detect changes over multiple timepoints. Kaplan-Meier analyses were used to compare the specifics of postoperative scarification.

Among the entire cohort, 17 individuals in the combined group were diagnosed with PCV, one with retinal arterial macroaneurysm, and one with haemorrhagic retinal detachment. In the vitrectomy-only group, 26 patients were diagnosed with PCV, six with retinal arterial macroaneurysm, and one with haemorrhagic retinal detachment. Preoperative data analysis revealed no significant differences between the two groups. Postoperatively, a significantly higher proportion of patients in the combined received intravitreal rt-PA than those in the vitrectomy-only group (Table 1).

Table 1

Differences Between Two Groups At Baseline VEGF = Vascular endothelial growth factor, PED = pigment epithelial detachment, RF = retinal fluid, CMT = central macular thickness, RT-PA = recombinant tissue plasminogen activator, IOP = intro-ocular pressure, PPV = pars plana vitrectomy.
	RT-PA + PPV	PPV	P values
Preoperative
Sex:Female/Male Age (years) Preceding anti-VEGF injections (in 1m) Duration of hemorrhag (days) Visual acuity (logMAR) Visual acuity (Snellen) PED area (µm²) PED height (µm) RF (µm²) CMT (µm) Systematic diseases Cataract surgery	7/12 66.21 ± 2.62 6/19 (31.58%) 20 (10,90) 2 (2, 2.3) 20/2,000 (20/2,000–20/4,000) 2.27 ± 0.32 (n = 17) 951.73 ± 118.74 2.76 ± 0.64 (n = 14) 761.14 ± 71.25 (n = 14) 7/19 12/19	15/18 67.33 ± 2.16 5/33 (15.15%) 20 (14,30) 2.3 (2, 2.3) 20/2,000 (20/2,000–20/4,000) 2.55 ± 0.57 (n = 16) 671.00 ± 88.69 2.02 ± 0.51 (n = 10) 759.57 ± 100.97 (n = 14) 17/33 24/33	0.545 0.711 0.296 0.818 0.599 0.986 0.099 0.705 0.990 0.307 0.472
Postoperative
IOP(the day after surgery, mmHg) Anti-VEGF injections (Within half a year) Maximum follow-up time (months)	14.41 ± 0.87 10:9 (52.63%) 4.30 ± 1.27	12.23 ± 0.72 4:29 (14.81%) 6.67 ± 1.05	0.06 0.01* 0.079

I. Visual Acuity

Regarding visual acuity, the preoperative average in the combined group was 2.07 ± 0.11 logMAR(Snellen 20/2,350), with a postoperative 1-month average of 1.68 ± 0.12 logMAR(Snellen 20/957), and postoperative 3-month average of 1.29 ± 0.14 logMAR(Snellen 20/390). In the vitrectomy-only group, the preoperative average was 1.89 ± 0.11 logMAR(Snellen 20/1,552), with a postoperative 1-month average of 1.51 ± 0.14 logMAR(Snellen 20/647) and postoperative 3-month average of 1.73 ± 0.19 logMAR(Snellen 20/1,074) (Fig. 2a). The combined group exhibited significant differences between preoperative and postoperative values in the first and third months (p = 0.005 and p<0.001 respectively). In contrast, the vitrectomy-only group showed a significant difference in visual acuity only in the first month after surgery (p<0.001).

II. Cross-Sectional Area and Height of PED

Within the combined group, 17 patients exhibited visible PED preoperatively, with a maximum average elevation area of 2.27 ± 0.32 µm². Postoperatively, this area was significantly decreased to 0.94 ± 0.24 µm² at 1 week, 0.87 ± 0.24 µm² at 1 month, and 0.56 ± 0.16 µm² at 3 months. In the vitrectomy-only group, 16 patients had visible PED preoperatively, with a maximum average elevation area of 2.55 ± 0.57 µm². Postoperatively, this area was decreased to 1.23 ± 0.29 µm² at 1 week, 1.04 ± 0.22 µm² at 1 month, and 0.67 ± 0.38 µm² at 3 months (Fig. 2b). Statistical analysis revealed significant differences in both groups at 1 week, 1 month, and 3 months postoperatively compared to preoperative values (p<0.001 for the combined group and p = 0.016, p = 0.003, p = 0.008 for the vitrectomy-only group). The same trend was observed in the height of PED, with both the combined and vitrectomy-only groups demonstrating significant variability at 1 week, 1 month, and 3 months postoperatively.

III. Central Macular Thickness (CMT)

In the combined group, the average preoperative CMT was 761.14 ± 71.25µm. Postoperatively, at 1 week, it reduced to 321.10 ± 48.91µm, followed by 290.62 ± 73.92µm at 1 month, and 285.33 ± 111.28µm at 3months. Conversely, in the vitrectomy-only group, the preoperative average CMT was 759.57 ± 100.97µm, which reduced to 549.08 ± 92.63µm at one week, 572.85 ± 96.85µm at one month, and 504.33 ± 132.59µm at 3 months (Fig. 2c). Statistical analysis indicated significant differences within the combined group between preoperative and postoperative values at 1 week, 1 month, and 3 months (p<0.001). In contrast, the vitrectomy-only group exhibited significant statistical differences only at 1 week(p = 0.005). Notably, significant differences between the two groups were observed at 1 week and 1 month postoperatively (p = 0.012 and p = 0.016, respectively).

IV. Retinal Fluid Cross-Sectional Area

Within the combined group, 14 patients presented visible RF preoperatively, with a maximum elevation cross-sectional area measuring 2.76 ± 0.64µm². Following surgery, this area decreased to 0.58 ± 0.13µm² at 1 week, 0.31 ± 0.61µm² at 1 month, and 0.19 ± 0.91µm² at 3 months. In the vitrectomy-only group, 10 individuals had visible RF preoperatively, with a maximum elevation area of 2.02 ± 0.51µm². Postoperatively, this area decreased to 1.40 ± 0.57µm² at 1 week, 1.80 ± 0.60µm² at 1 month, and 0.98 ± 0.65µm² at 3 months (Fig. 2d). Statistical analysis revealed significant differences within the combined group between preoperative and postoperative values at 1 week, 1 month, and 3 months showing an average decrease of 2.57µm² over 3 months. In contrast, the vitrectomy-only group did not exhibit significant differences between time intervals. Notably, significant differences between the two groups were observed at 1 week and 3months postoperatively (p = 0.013).

V. Postoperative Outcomes

None of the patients had preexisting macular scars before surgery. Among the 19 patients in the combined group, two experienced intravascular fibrosis after surgery. In contrast, in the vitrectomy-only group consisting of 33 individuals, 13 developed intravascular fibrosis during the follow-up period, demonstrating a statistically significant difference between the two groups (Fig. 3). The mean value of survival time was 14.70 months in the combination group and 12.40 months in the PPV-only group, there was no statistical significance in survival between the two groups(p = 0.215).

In terms of the incidence of postoperative complication: in the combined group, one patient developed vitreous haemorrhage 1 month postoperatively, necessitating a second air-fluid exchange procedure. Another patient underwent a subsequent oil injection. In the vitrectomy-only group, six patients experienced postoperative complications, including one with recurrent retinal detachment, three with vitreous haemorrhage, one with anterior chamber haemorrhage, and two with unresolved retinal detachment. Statistical analysis revealed no significant differences between the groups regarding complications (Table 2).

Table 2

Comparison of Postoperative Regression Between The Two Groups
	RT-PA + PPV	PPV	P values
Fibrillation Complication	2/19 (10.53%) 2/19 (10.53%)	13/33 (39.40%) 6/33 (8.18%)	0.027* 0.736

VI. Correlation Analysis

No significant correlation was observed between the duration of symptoms, preoperative use of anti-VEGF drugs and the improvement in visual acuity at 3 months postoperatively compared with those at baseline in either group.

In addressing subretinal haemorrhage, clinicians face the crucial task of selecting the most appropriate treatment approach for each patient. In our study, we conducted a comparative analysis of two commonly employed surgical methods, specifically evaluating the impact of a combination of rt-PA and vitrectomy versus vitrectomy alone. Notably, patients treated with the combined approach exhibited significant improvements in visual acuity at 1 month postoperatively, accompanied by notable reductions in CMT, maximum cross-sectional area of PED, RF, and maximum height of PED at 1 week postoperatively. The toxic effects of SMH on the macula became evident as early as 24 hours after the onset of bleeding (9), subretinal hyperreflective material(SHRM)has a direct toxic effect on overlying photoreceptors, impeding nutrient and metabolite exchange between RPE and photoreceptors, directly contributing to the progression of scarring (10, 11). Robert et al.'s study of the relationship between SHRM and fibrosis showed that eyes with fibrosis had significantly greater SHRM thickness and volume at month 3 (12), this could also explain the poor CMT and visual acuity in our vitrectomy-only group at the third month. Our finding highlights the importance of an early response, as the sooner the intervention, the more normalised the macular morphology and function. Prolonged postoperative proved effective in reducing the likelihood of fibrosis or scarring in the vascular arch of the posterior pole.

PCV being an active disease prone to recurrence, necessitates long-term postoperative surveillance. The combined group demonstrated sustained recovery across various indicators, while the vitrectomy-only group exhibited improvement at 1 month but displayed a trend of disease worsening at 3 month compared with the status at 1 month. In the vitrectomy-only group, significant differences were observed mainly in the retinal morphology postoperatively, with suboptimal recovery of the macular structure and unsatisfactory visual outcomes. This may be attributed to the potential second-phase activity of the disease. Moreover, a previous study suggests that age is a risk factor for the secondary recurrence of PCV after stabilisation (13). While no statistically significant differences in the probability of occurrence of postoperative complications were noted between the two groups, the combined group exhibited nearly half the probability of occurrence compared with the vitrectomy-only group.

Certain limitations of this study should be acknowledged. First, a higher proportion of postoperative patients in the combined group receiving intravitreal anti-VEGF injections on a 3 + prn regimen, which introduces a potential bias. Studies have shown that 40% of patients under long-term anti-VEGF treatment do not develop fibrosis, however, this indicates that more than half patients lose their vision due to subretinal scarring (14). Cheung et al. stated that subretinal fibrosis is the most important predictor and clinical observation of final vision (15). Our research found that regular postoperative anti-VEGF treatment combined with subretinal injection of rt-PA may effectively contributed to halting the progression of subretinal fibrosis. Second, some patients could have influenced experienced cataract surgery during or after the intervention, which could have influenced visual acuity, although no significant difference was noted in the proportion of patients with cataract removal between the two groups. Furthermore, as we sought a more clinically pragmatic treatment option, patients’ lens opacity may worsen after vitrectomy; therefore, the inclusion of cataract surgery in the treatment pathway, when necessary, would have aligned with a more pragmatic clinical outcome (16). Our study also recognised a young subgroup of patients in the vitrectomy-only group who did not receive concomitant anti-VEGF treatment, showing visual acuity improvement from 0.08 to 1.0 postoperatively, possibly influenced by age. Plus, the follow-up period in this trial was not long enough, and Ebenezer Daniel et al. found that half of the eyes that underwent Age-related Macular Degeneration Treatments Trials developed scarring after 2 years (13), so this cohort of patients could be continued to be followed up in future studies to further observe the long-term prognosis of scarring.

Studies like Jeong et al.'s work on SMH caused by neovascular age-related macular degeneration (nAMD) emphasise the importance of tailored interventions based on the size of SMH, such as small-sized SMH responds well to anti-VEGF therapy, whereas medium- to large-sized SMH often requires combined PPV for better visual prognosis (17) .

In conclusion, our findings advocate for considering a combination of rt-PA and regular postoperative anti-VEGF treatment, especially for patients with PCV prone to significant haemorrhage, particularly those with SMH exceeding ≥ 4 disc diameters(18). This approach aims to achieve optimal blood clearance, prevent retinal pigment epithelium tears, enhance the self-repair capacity of retinal morphology, and effectively prevent disease recurring.

Conflict of interest

There is no conflict of interest

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Comparative analysis of anatomy and fibrosis formation between vitrectomy and vitrectomy combined with intravitreal rt-PA injection into the subretinal macular space for submacular haemorrhage

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Abstract

Figures

Introduction

Methods

Research Population

Procedure

Measurement

Statistical Analysis

Results

Discussion

Declarations

Conflict of interest

References

Additional Declarations

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