Vitrectomy or pneumatic displacement may result in better outcomes than anti-VEGF therapy for those with large submacular hemorrhage. Click image to enlarge.

There are several treatment options for submacular hemorrhage (SMH), a serious complication of neovascular age-related macular degeneration (nAMD), ranging from vitrectomy to expansile gas injection; however, until a recent study, no single option was considered optimal. The study examined SMH characteristics in a Japanese population, more prone to SMH, and recommended either vitrectomy or pneumatic displacement for visual improvement in SMH secondary to nAMD exceeding two disc areas with BCVA below 20/40.

The retrospective multicenter study included 127 eyes (mean patient age: 74) diagnosed with AMD-associated SMH exceeding two disc diameters and involving the fovea. The researchers assessed AMD types, prior treatments, treatment options, anatomic findings and BCVA.

A total of 25% of eyes had typical AMD, 74% had polypoidal choroidal vasculopathy (PCV) and one eye had retinal angiomatous proliferation. A total of 67% eyes were treatment-naïve, and 33% had undergone previous treatment (anti-VEGF, photodynamic therapy and combined therapy).

Patients had been treated with vitrectomy (28%), pneumatic displacement (39%) or anti-VEGF monotherapy (33%). Treatment-naïve cases experienced BCVA improvements from 20/145 to 20/83, and in PCV cases, 20/126 to 20/73. BCVA improved from 20/283 to 20/112 in vitrectomized eyes and from 20/148 to 20/85 in pneumatic displacement-treated eyes.

Eyes with BCVA between 20/133 and 20/40 at SMH onset had better final visual acuity after pneumatic displacement than anti-VEGF monotherapy. Adverse events during the study period included one eye with a retinal detachment, one eye in the vitrectomy group with a macular hole and five eyes in the pneumatic displacement group with vitreous hemorrhage.

The researchers concluded that eyes with good visual acuity at SMH onset and those with small SMH can maintain visual acuity with anti-VEGF monotherapy. “However, in eyes with large SMH, pneumatic displacement or vitrectomy is recommended,” they wrote in their paper. “Especially in eyes with BCVA between 20/40 and 20/133 and moderate-sized SMH, pneumatic displacement can achieve concomitant visual improvement.”

Inoue N, Kato A, Araki T, et al. Visual prognosis of submacular hemorrhage secondary to age-related macular degeneration: a retrospective multicenter survey. PLoS One. July 21, 2022. [Epub ahead of print].