Vitrectomy for submacular hemorrhage remains unproven and controversial. The clinical course of submacular hemorrhages can vary. Patients with neovascular age-related macular degeneration (AMD) and larger submacular hemorrhages generally have poor visual outcomes. For removal of thick submacular hemorrhages, pars plana vitrectomy techniques can be considered. The surgery involves pneumatic displacement of subretinal blood away from the macular center without attempting to remove the hemorrhage. This technique can be performed with a vitrectomy, subretinal injection of tissue plasminogen activator (tPA) via a 39-gauge to 41-gauge cannula, and partial air–fluid exchange. Postoperative face-down positioning can result in substantial inferior extramacular displacement of the blood (Fig 20-5). Intravitreal injection of expansile gas (eg, SF6 or C3F8) and face-down positioning, with or without adjunctive intravitreal tPA administration, has also been performed in an office setting. Resolution of submacular hemorrhage with improvement of visual acuity can be achieved with administration of anti-VEGF agents alone, particularly if the blood is of mild thickness. Following treatment of the submacular hemorrhage, most patients require chronic treatment for the exudative AMD, usually with anti-VEGF injections.
Figure 20-5 Fundus photographs of submacular hemorrhage in age-related macular degeneration (AMD). A, Patient had a submacular hemorrhage for 5 days and counting-fingers vision. B, After vitrectomy with subretinal infusion of tissue plasminogen activator and pneumatic displacement, dry atrophic changes are apparent. Visual acuity improved to 20/100.
(Courtesy of Nancy M. Holekamp, MD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.