Management of Traumatic Submacular Hemorrhage by Pneumatic Displacement: A Review

Traumatic submacular haemorrhage is a vision-threatening ocular emergency that can result in permanent visual loss if not treated promptly. Following blunt ocular trauma, rapid accumulation of blood beneath the macula leads to photoreceptor damage through iron-mediated oxidative stress, mechanical disruption, and impaired metabolic exchange. Pneumatic displacement, with or without intravitreal tissue plasminogen activator (tPA), has emerged as a minimally invasive therapeutic option; however, standardized clinical guidelines for its use in traumatic cases remain lacking. A narrative literature search was conducted across Scopus, Web of Science, Medline, Embase, PubMed, OpenAlex, and Dimensions up to November 24, 2025, supplemented by citation tracking. After duplicate removal and title/abstract screening, full-text assessment was performed based on predefined inclusion criteria focusing on traumatic submacular haemorrhage managed with pneumatic displacement. Of 177 identified records, four studies met the final eligibility criteria. The available evidence suggests that pneumatic displacement using intravitreal gas alone, most commonly 100% perfluoropropane (C₃F₈), achieved anatomical displacement in some cases but showed lower functional success, particularly in thick or dense haemorrhages. In contrast, intravitreal tPA combined with expansile gas was the most frequently employed minimally invasive approach and resulted in high rates of complete subfoveal blood displacement and clinically meaningful visual improvement, especially in younger patients. Pars plana vitrectomy with subretinal tPA was reserved for large or complex haemorrhages and produced favorable outcomes, albeit with higher surgical risk. Although the current evidence is limited, largely retrospective, and derived from small-sample studies, early treatment appears to be associated with favorable anatomical and functional outcomes. Intravitreal tPA combined with pneumatic displacement appears to be the most effective first-line therapy, while gas-only displacement may be considered when tPA is unavailable. Well-designed prospective studies with standardized outcome measures are needed to define optimal management strategies.