Cost-Effectiveness of Alternative Treatment Strategies of Subretinal Macular Hemorrhage

Purpose: To evaluate the cost-effectiveness of alternative treatment strategies for subretinal macular hemorrhage (SRMH), a condition often associated with neovascular age-related macular degeneration (AMD) and other retinal vascular disorders, leading to severe visual impairment. Methods: A retrospective cross-sectional study conducted at Oslo University Hospital assessed the cost and utility of various SRMH treatment modalities. These included intravitreal anti-VEGF monotherapy, intravitreal tissue plasminogen activator (tPA) with gas displacement (alone and in combination with anti-VEGF), and pars plana vitrectomy (PPV) with subretinal tPA and gas displacement (with and without anti-VEGF). Costs were analyzed from a healthcare perspective, encompassing direct and indirect costs. Effectiveness was measured using median best-corrected visual acuity (BCVA) improvements. Sensitivity analyses were performed to account for complications and variations in follow-up. Results: Anti-VEGF monotherapy was the most cost-effective treatment, with the lowest cost per unit of BCVA improvement (NOK 44,717) in outpatient settings. Intravitreal tPA with gas displacement emerged as a cost-effective alternative but exhibited higher costs when combined with anti-VEGF or performed as an inpatient procedure. PPV with subretinal tPA and gas displacement, with or without anti-VEGF, was the least cost-effective modality, particularly in inpatient settings. Sensitivity analyses indicated that anti-VEGF therapy remained cost-effective even with increased follow-up requirements and complications, while tPA-based therapies required significant BCVA improvements to match anti-VEGF's cost-utility. Conclusions: Outpatient intravitreal anti-VEGF monotherapy followed by tPA with gas displacement are the most cost-effective strategies for SRMH management. Subretinal tPA-based treatments are associated with higher costs and limited economic viability, highlighting the importance of tailored treatment selection. These findings support strategic resource allocation in managing SRMH while optimizing patient outcomes.