Subretinal injection of tissue plasminogen activator for submacular hemorrhage - When and how to do

Submacular hemorrhage (SMH) causes irreversible loss of vision as it causes permanent anatomical and functional damage to photoreceptors. The various causes include polypoidal choroidal vasculopathy, neovascular age-related macular degeneration, retinal artery macroaneurysm, high myopia, and trauma. The current treatment modalities include antivascular endothelial growth factor (anti-VEGF) monotherapy, anti-VEGF ± gas pneumatic displacement ± intravitreal recombinant tissue plasminogen activator injection (rtPA), and triple therapy (intravitreal anti-VEGF + intravitreal rtPA + perfluoropropane gas injection). The surgical displacement of the SMH by vitrectomy with subretinal tissue plasminogen activator injection + intravitreal anti-VEGF + gas tamponade has been a valuable addition to our armamentarium. Evidence suggests that this novel technique provides better anatomical and functional outcomes in terms of visual acuity when the surgical displacement is performed within the prompt time frame in comparison to other available modalities of treatment. The current lacuna in the literature is the absence of level 1 evidence to support the surgical displacement as the first-line therapy. Hence, we review the current evidence and provide recommendations regarding this ever-promising therapy that can be vision-saving.