What is the treatment approach for a patient with a submacular bleed in the retina, considering potential underlying conditions such as diabetic retinopathy?

Treatment of Submacular Hemorrhage in the Retina

For submacular hemorrhage, immediate intervention with vitrectomy, subretinal tissue plasminogen activator (tPA) injection, intravitreal anti-VEGF, and gas tamponade provides the best anatomical and functional outcomes when performed within one week of symptom onset, particularly for thick hemorrhages. 1, 2

Initial Assessment and Timing

The critical window for intervention is within 7 days of hemorrhage onset, as this timeframe minimizes irreversible photoreceptor damage from blood toxicity and mechanical separation. 1, 3 Key assessment parameters include:

• Hemorrhage thickness and size: Measure in disc areas (DA) using OCT and fundus examination 4, 3
• Duration of symptoms: Document exact time from onset, as outcomes deteriorate significantly after one week 1, 3
• Underlying etiology: Identify if secondary to neovascular AMD, polypoidal choroidal vasculopathy, retinal arterial macroaneurysm, high myopia, or trauma 1, 2
• Visual acuity at presentation: Baseline VA predicts treatment response 4, 3

Treatment Algorithm by Hemorrhage Characteristics

For Thick Hemorrhages (≥2 Disc Areas) Presenting ≤1 Week

Primary approach: Surgical displacement via pars plana vitrectomy with:

• Subretinal tPA injection (12.5-25 mcg) 1, 2
• Intravitreal anti-VEGF (bevacizumab 1.25 mg or ranibizumab 0.5 mg) 1, 3
• Gas tamponade (perfluoropropane or sulfur hexafluoride) 1, 2
• Postoperative face-down positioning 2

This surgical approach achieves superior hemorrhage displacement compared to pneumatic displacement alone, though visual outcomes may be comparable. 2

For Smaller Hemorrhages (<4 Disc Areas) or When Surgery Not Immediately Available

Alternative approach: Pneumatic displacement with:

• Intravitreal tPA (25-50 mcg) - optional but may facilitate displacement 2
• Intravitreal anti-VEGF injection 4, 3
• Expansile gas (0.3-0.4 mL perfluoropropane or sulfur hexafluoride) 2
• Face-down positioning for 3-7 days 2

For Hemorrhages Presenting >1 Week or Predominantly Hemorrhagic Lesions (>50% blood)

Consider anti-VEGF monotherapy when:

• Hemorrhage is predominantly from neovascular AMD 4, 3
• Patient presents beyond the optimal surgical window 3
• Surgical risks outweigh benefits 4

Protocol: Monthly intravitreal bevacizumab (1.25 mg) or ranibizumab (0.5 mg) until hemorrhage resolution, then treat-and-extend based on OCT findings. 3 Complete hemorrhage resolution occurs in 96% of cases within one year, with mean resolution time of 4.8 months. 4, 3

Expected Outcomes by Hemorrhage Size

Visual prognosis correlates inversely with hemorrhage size at presentation:

• Group A (1-4 DA): 57% gain ≥1 ETDRS line 4
• Group B (4-9 DA): 53% gain ≥1 ETDRS line 4
• Group C (≥9 DA): 38% gain ≥1 ETDRS line 4

Eyes with smaller hemorrhages have better chances of stabilized or improved vision regardless of treatment modality. 4

Critical Complications to Monitor

Vitrectomy-specific complications:

• Macular hole formation - particularly high risk in retinal arterial macroaneurysm cases, representing a significant complication requiring immediate recognition 2
• Retinal detachment - more prevalent following vitrectomy than pneumatic displacement 2

Pneumatic displacement complications:

• Breakthrough hemorrhage - more common than with vitrectomy 2
• Inadequate displacement requiring conversion to vitrectomy 2

Both approaches:

• Elevated intraocular pressure from gas expansion 2
• Recurrent hemorrhage from persistent neovascularization 1, 4

Sequential Treatment Strategy

When initial pneumatic displacement achieves insufficient hemorrhage displacement, proceed immediately to vitrectomy with subretinal tPA injection and gas tamponade rather than repeating pneumatic displacement. 2 This sequential approach optimizes outcomes while minimizing unnecessary surgical intervention.

Adjunctive Anti-VEGF Management

Following hemorrhage clearance, continue anti-VEGF therapy targeting the underlying neovascular process using treat-and-extend protocols. 4, 3 Mean treatment requires 11.4 injections over 18.4 months for complete disease control. 3

Context for Diabetic Retinopathy

While submacular hemorrhage can occur in diabetic retinopathy, it is uncommon compared to vitreous hemorrhage. 5 When present, the treatment principles above apply, though the underlying diabetic neovascularization requires additional panretinal photocoagulation or continued anti-VEGF therapy per standard diabetic retinopathy protocols. 6