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Surgical Technique |

Subretinal Pneumatic Displacement of Subretinal Hemorrhage

Joseph N. Martel, MD1; Tamer H. Mahmoud, MD, PhD1
[+] Author Affiliations
1Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
JAMA Ophthalmol. 2013;131(12):1632-1635. doi:10.1001/jamaophthalmol.2013.5464.
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Massive submacular hemorrhage can cause disastrous visual complications. Prompt displacement away from the fovea is desirable in some patients. We describe a novel surgical technique involving subretinal air as a therapeutic adjuvant for massive submacular hemorrhage displacement.

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Figure 1.
Subretinal Therapeutic Cocktail Injection

A 41-gauge needle is used to access the subretinal space within the clotted hemorrhagic retinal detachment (A). Subretinal tissue plasminogen activator and an anti–vascular endothelial growth factor agent are injected causing liquefaction of the submacular hemorrhage (inside red circle) and a subretinal fluid bleb (blue) with expansion of the retinal detachment borders (B).

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Figure 2.
Subretinal Pneumatic Injection

Subretinal air (green) is placed to minimize the buoyancy of the liquefied submacular hemorrhage (A), facilitating inferior displacement of the submacular hemorrhage (B).

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Figure 3.
Fundus Photography and Horizontal Line Scan Spectral-Domain Optical Coherence Tomography (SD-OCT)

A, Preoperative fundus photograph and horizontal line scan SD-OCT demonstrating massive submacular hemorrhage with a hemorrhagic retinal detachment. B, One-month postoperative fundus photograph and horizontal line scan SD-OCT demonstrate marked interval improvement in the submacular hemorrhage and retinal architecture with residual small hyperreflective pigment epithelial detachments.

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Figure 4.
Principal Force Vectors (Not Drawn to Scale) Governing Movement of Red Blood Cells Within the Submacular Space

A, Frictional and buoyancy forces counteract the gravitational force limiting movement of clotted submacular hemorrhage. B, The clot is immersed in subretinal tissue plasminogen activator (rTPA) (blue), decreasing the frictional force while appropriate positioning maximizes the gravitational force. C, Subretinal air (green) greatly decreases the buoyancy of the liquefied clot.

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