Review of current management of submacular hemorrhage

Subretinal hemorrhage (SRH) is most commonly associated with neovascular age-related macular degeneration (nAMD) and can cause profound vision loss in the macula through mechanical, toxic, and inflammatory mechanisms. Submacular hemorrhage (SMH) lacks consensus on management. This review summarizes current treatment options, key comparative studies, and ongoing challenges, with emphasis on SMH management.

Antivascular endothelial growth factor (anti-VEGF) therapy remains central to SMH management, with outcomes comparable to surgery in small to moderate hemorrhages. Pneumatic displacement (PD) with or without recombinant tissue plasminogen activator (rtPA) shows the greatest comparative benefit in more extensive SMH. Adjunctive rtPA improves hemorrhage displacement rates, and meta-analyses support its efficacy with anti-VEGF therapy. Pars plana vitrectomy (PPV) remains an option for large or refractory hemorrhages but has not consistently shown superior visual outcomes compared to less invasive modalities.

Early intervention is consistently associated with improved outcomes, but there is no universally accepted treatment algorithm. Ongoing randomized trials and advances in multimodal imaging have the potential to refine patient selection and treatment strategies. Future efforts should focus on balancing efficacy, safety, and cost-effectiveness to establish evidence-based guidelines for SMH management.