Submacular Hemorrhage

One morning, an 83-year-old woman woke up to find a gray-colored spot in the central vision of her right eye. The spot was constant, and she could not see through it. She had a history of dry age-related macular degeneration and cataract surgery in both eyes.

The best corrected visual acuity was 20/200 in the right eye and 20/80 in the left eye. The eyes were pseudophakic. Funduscopic examination showed significant hemorrhages in the macular and perimacular retina of the right eye (A) that represented new-onset wet macular degeneration from a choroidal neovascular membrane. Both intraretinal (bright red) and subretinal (dark) hemorrhages were visible.

The prognosis is poor for the vision of patients with untreated macular subretinal hemorrhage. This type of hemorrhage causes:

• Direct toxicity to photoreceptors from iron released during hemoglobin breakdown.

• Clots that act as a barrier, which impairs metabolic exchange between the photoreceptors and retinal pigment epithelium.

• Mechanical damage from clot contraction.

• Subretinal fibrosis.

There is no medical therapy for submacular hemorrhage. Surgery can in some cases stabilize and even improve vision. Patients most likely to benefit from surgery are those who had good visual acuity before the hemorrhage and whose hemorrhage had been present for less than 2 weeks and was larger than 3 disc diameters in greatest linear dimension.

This patient underwent surgery, which included intraocular vitrectomy, injection of tissue plasminogen activator to dissolve the clot, submacular hemorrhage evacuation, pneumatic displacement using expansible inert gas, and intravitreal injection of an antivascular endothelial growth factor agent to stabilize the neovascular membrane. One year later, her vision in the right eye had improved to a best corrected visual acuity of 20/80. The funduscopic examination at that time showed no remaining hemorrhage. Stable hyperpigmented and hypopigmented scar tissue was evident (B).