Update on medical and surgical management of submacular hemorrhage

ABSTRACT

Introduction: Despite consistent use of anti-vascular endothelial growth factor (anti-VEGF), prognosis of large, fovea-involving submacular hemorrhage (SMH) has remained guarded, particularly in patients with neovascular age-related macular degeneration.

Areas covered: This review provides an update on management of SMH, with particular focus on the role of anti-VEGF therapy and surgical management of thick, large, and/or subfoveal SMH. A literature search and meta-analysis of studies published from January 2010 to February 2019 was performed to evaluate outcomes of eyes with SMH following management with either medical treatment (i.e. anti-VEGF monotherapy) or a combined surgical approach of pars plana vitrectomy, subretinal tPA with or without subretinal air, pneumatic displacement, and anti-VEGF. The surgical techniques are summarized, with emphasis on novel surgical techniques described in the past decade. Prognostic factors associated with, and potential indications for, choice of management approach were evaluated.

Expert commentary: SMH represents a continuing treatment challenge. Anti-VEGF monotherapy is a reasonable approach in patients with small, thin, and localized hemorrhage. Combination vitrectomy, tPA, pneumatic displacement, and anti-VEGF may be effective in managing thick, large SMH in some cases. While no consensus exists on optimal treatment algorithm, choice of medical or surgical therapy should be tailored to each patient.

KEYWORDS:

• Anti-VEGF
• submacular hemorrhage
• subretinal hemorrhage
• tPA
• vitrectomy
• neovascular AMD

Article Highlights

• Treatment of submacular hemorrhage (SMH) has evolved over the last decade, with both anti-VEGF monotherapy and combined surgical techniques yielding improved visual acuity.

• The protocol and treatment outcome of one approach to the combined surgical technique of small-gauge pars plana vitrectomy with subretinal tPA, pneumatic displacement, and anti-VEGF has been shown.

• Combination of vitrectomy, subretinal tPA with/without subretinal air, pneumatic displacement, and anti-VEGF resulted in greater letter improvement compared to anti-VEGF monotherapy but involved patients with worse visual acuity and larger size hemorrhage at baseline; the final visual acuity following the combined approach was less than that of anti-VEGF monotherapy.

• Anti-VEGF monotherapy may be preferred in patients with small, thin SMH or those who are poor surgical candidates. Combined surgical approach may be indicated in those with large, thick SMH or with poor response to initial management with anti-VEGF. The future of SMH management will lie in advancements to both anti-angiogenic pharmacotherapy (alternative agents affecting different specific pathways in SMH pathophysiology, long-acting drug delivery systems), as well as surgical techniques and instrumentation that will complement each other.

Supplementary material

The supplemental data for this article can be accessed here.

Declaration of interest

B. Todorich has financial interest with Genentech, Allergen, Regeneron and Vortex Surgical. They have also served on the advisory boards of Genentech, Allergen and Regeneron. T. Mahmoud has a financial interest with Vortex Surgical. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

TH Mahmoud has a financial interest with Vortex Surgical. B Todorich has financial interest with Genentech, Allergan, Regeneron and Vortex Surgical. B Todorich has also served on the advisory boards of Genentech, Allergan, and Regeneron. AQ Lu, JG Prensky, PS Baker, and IU Scott have no conflicts of interest with respect to the research, authorship, and/or publication of this article to declare.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.