Management of submacular hemorrhage: from a case report to a comprehensive review of current treatment strategies

TL;DR

This paper reviews current treatments for submacular hemorrhage, a serious eye condition, and highlights the best strategies based on hemorrhage size and timing of intervention.

Contribution

The paper provides a comprehensive review and analysis of pharmacological and surgical treatment strategies for submacular hemorrhage.

Findings

Pharmacological treatments like anti-VEGF therapy are as effective as surgery for small hemorrhages and safer.

Combining tPA and anti-VEGF therapy achieves high displacement success rates.

Surgical methods like pneumatic displacement and vitrectomy are effective for larger or organized hemorrhages.

Abstract

To evaluate current pharmacological and surgical strategies for managing submacular hemorrhage (SMH), a vision-threatening complication which primarily occurs with macular neovascularization in age-related macular degeneration (AMD).

The research involved a literature review of recent studies about SMH treatment methods including anti-vascular endothelial growth factor (VEGF) therapy, tissue plasminogen activator (tPA), pneumatic displacement and pars plana vitrectomy techniques through meta-analyses, comparative studies and case series.

SMH treatment is guided by hemorrhage size: small (≥ 1 to < 4 disc diameters), medium (≥ 4 disc diameters within the temporal arcade), massive (exceeding temporal arcades). Pharmacological management includes anti-VEGF monotherapy, which demonstrates efficacy comparable to surgical interventions for smaller hemorrhages, while offering a superior safety profile. Combined of tPA and anti-VEGF therapy achieves an 86% displacement success rate, with comparable efficacy between subretinal and intravitreal delivery methods. Surgical methods include pneumatic displacement, which achieves 85–100% efficacy in displacement and 45–80% rates of visual improvement, whereas pars plana vitrectomy is preferred for cases involving dense, organized hemorrhages. Retrospective studies indicate that outcomes are primarily influenced by patient-specific factors, such as hemorrhage size and baseline visual acuity, rather than the treatment modality employed. Intervention within 7 to 14 days has been shown to enhance outcomes, particularly when using a stepwise protocol that begins with less invasive techniques and escalates only as necessary.

Modern SMH management emphasizes individualized, time-sensitive treatment based on hemorrhage characteristics. A stepwise approach, beginning with pharmacological therapy and moving to surgery only when necessary, tends to offer the best balance between visual recovery and safety. Timely diagnosis and intervention are essential factors for success due to the rapid damage of photoreceptors occurring within 24–72 h of onset.

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