Vitrectomy for Subretinal and Submacular Hemorrhages

Abstract

Submacular hemorrhage (SMH) is relatively rare in retinal practice. However, it is an important complication of many choroidal and retinal diseases, particularly neovascular age-related macular degeneration (AMD). When untreated the visual prognosis is poor, especially in patients with AMD, and SMHs cannot be effectively treated with only anti-vascular endothelial growth factor (anti-VEGF) injection. The current therapeutic approach is based upon the displacement of the subretinal hemorrhage away from the central retina as soon as possible. The use of tissue plasminogen activator (tPA) has been an important milestone in the treatment of SMHs. Current vitrectomy techniques for SMH management include subretinal tPA injection and aspiration of the blood, and subretinal tPA, and air/anti-VEGF injection with gas tamponade. Submacular surgery, which involves removal of the SMH and choroidal neovascularization (CNV) through a retinotomy, seems to be a technique reserved for selected cases where central retinal pigment epithelium appears to be undiseased/uninvolved. Among the non-surgical treatment options, pneumatic displacement with intravitreal tPA and gas injection may be preferred especially for small-medium sized and thin SMHs. However, the favored approach in real-life conditions is shaped by the physician's experience and the available treatment options. Regardless of the preferred approach, the continuity of the treatment of the underlying pathology is important. As the underlying pathology is usually a CNV, the continuation of anti-VEGF treatment is important for maintaining the visual gain of the initial treatment and reducing the risk of recurrent SMH. The breakthrough development rate of the drugs and the surgical techniques for the treatment of retinal diseases promises in terms of new and more effective treatment approaches.