An 82-year-old patient presented in the emergency room with acute vision loss of the left eye (OS), with no other associated symptoms. OS funduscopy revealed a large macular subretinal and sub-inner limiting membrane (ILM) hemorrhage—a hemorrhagic pattern known as hourglass hemorrhage. The patient underwent surgery, consisting of phacoemulsification, vitrectomy, peeling of the ILM and subretinal injection of 0.04-mL tissue plasminogen activator (tPA, 0.125 mg/0.1 mL) with a 41-gauge cannula. One week after surgery, the hemorrhage was almost completely reabsorbed. Fluorescein angiography performed two weeks after surgery showed focal dilation of the superior-temporal retinal arteriole corresponding to a retinal arterial macroaneurysm. Hourglass hemorrhage following a retinal macroaneurysm rupture can be an important cause of irreversible vision loss. Recovery can be safely achieved by performing the technique showed in this video with prompt ILM peeling and subretinal injection of tPA.