Update on medical and surgical management of submacular hemorrhage

Introduction: Despite consistent use of anti-vascular endothelial growth factor (anti-VEGF), prognosis of large, fovea-involving submacular hemorrhage (SMH) has remained guarded, particularly in patients with neovascular age-related macular degeneration. Areas covered: This review provides an update on management of SMH, with particular focus on the role of anti-VEGF therapy and surgical management of thick, large, and/or subfoveal SMH. A literature search and meta-analysis of studies published from January 2010 to February 2019 was performed to evaluate outcomes of eyes with SMH following management with either medical treatment (i.e. anti-VEGF monotherapy) or a combined surgical approach of pars plana vitrectomy, subretinal tPA with or without subretinal air, pneumatic displacement, and anti-VEGF. The surgical techniques are summarized, with emphasis on novel surgical techniques described in the past decade. Prognostic factors associated with, and potential indications for, choice of management approach were evaluated. Expert commentary: SMH represents a continuing treatment challenge. Anti-VEGF monotherapy is a reasonable approach in patients with small, thin, and localized hemorrhage. Combination vitrectomy, tPA, pneumatic displacement, and anti-VEGF may be effective in managing thick, large SMH in some cases. While no consensus exists on optimal treatment algorithm, choice of medical or surgical therapy should be tailored to each patient.