Age Related Macular Degeneration - Massive Submacular Hemorrhage with TPA

The above photos show a massive submacular hemorrhage in a patient with neovascular macular degeneration taking clopidogrel and warfarin. This 84 year man complained of sudden loss of vision in the left eye four days before. The visual acuities were count fingers at 4 feet in both eyes. Six months earlier, the vision in the left was 20/32. He had a dry subretinal scar in the right eye. The left eye had inactive subretinal neovascularization with ongoing treatment with aflibercept injections. The slit lamp exam was normal except intraocular lens implants bilaterally. The fundus exam showed a dry subretinal scar in the right eye. Subretinal blood is indicated by pink arrows. Preretinal blood is indicated by blue arrows. Due to large hemorrhage a vitrectomy with the subretinal injection of tissue plasminogen activator (TPA, 25 micrograms/ml) into the clot followed by gas-fluid exchange was done. The TPA dissolves the clot and the gas, combined with positioning, displaces the liquefied blood inferiorly away from the macula.