Journal of Clinical Medicine · 10 authors, 7 centres
This summary was generated by AI from a single paper. It has not been reviewed by a clinician and is not clinical advice. Verify against the source before acting on it.
This systematic review of 81 studies on subretinal macular hemorrhage (SRMH) secondary to age-related macular degeneration found that while various treatments (anti-VEGF, pneumatic displacement, vitrectomy, rt-PA) show promise, no single modality is conclusively superior. The evidence is limited by small, retrospective studies, highlighting the need for larger prospective trials to guide clinical decision-making.
**Background:** Subretinal macular hemorrhage (SRMH) is a sight-threatening condition characterized by blood accumulation between the neurosensory retina and retinal pigment epithelium, most commonly due to neovascular age-related macular degeneration (n-AMD). Without treatment, visual prognosis is poor, with only 11% of untreated eyes achieving final best-corrected visual acuity (BCVA) better than 6/60. The natural history leads to fibrotic macular scar (38%), atrophy (25%), or RPE rupture (22%). Various treatments exist, including anti-VEGF monotherapy, pneumatic displacement, vitrectomy with or without recombinant tissue plasminogen activator (rt-PA), and photodynamic therapy, but no consensus on optimal management exists.
**Methods:** A systematic review was conducted following PRISMA guidelines, searching Ovid Medline, Embase, Cochrane Register of Controlled Trials, and Cochrane Database of Systematic Reviews from inception to 14 June 2022. Search terms included (subretinal OR submacular) AND (hemorrhage OR haemorrhage OR bleeding). Inclusion criteria: studies analyzing outcomes of SRMH treatment in n-AMD. Exclusion criteria: reviews, pilot studies, letters, case series ≤12 eyes, case reports, photo essays, non-English studies, animal/cadaveric/pediatric studies, and SRMH from other etiologies. Two reviewers screened titles/abstracts and full texts, with third-party adjudication. Quality was assessed using the GRADE system.
**Key Results:** Of 2745 initial articles, 1654 remained after duplicate removal and abstract screening; 155 underwent full-text review, and 81 met inclusion criteria. The review identified only a few prospective or randomized controlled trials (RCTs), with most evidence from retrospective studies. Key prospective studies included: Gopalakrishan et al. and De Jong et al. on pneumatic displacement; Iacono et al. on anti-VEGF; Wei et al., Mozafarieh et al., Kadonosono et al., Kimura et al., and De Jong et al. on vitrectomy with/without rt-PA. Retrospective studies by Ueda-Arakawa et al. and Maggio et al. explored watchful waiting for mild cases. Pneumatic displacement showed encouraging visual outcomes but lacked long-term data. Anti-VEGF demonstrated promise but had modest sample sizes and no consensus on regimens. Surgical interventions (vitrectomy ± rt-PA) were effective for larger/dense hemorrhages but carried risks (e.g., RPE tear, retinal detachment, cataract). Photodynamic therapy (PDT) was investigated in retrospective studies (e.g., Lin et al.) but evidence was insufficient. The review noted that timing of intervention and hemorrhage size are crucial prognostic factors.
**Clinical Implications:** The management of SRMH remains challenging with no definitive best treatment. Intravitreal anti-VEGF is minimally invasive and effective in some cases but may require multiple injections and is less effective for massive hemorrhage or fibrosis. Pneumatic displacement is less invasive than vitrectomy but can cause subretinal blood displacement. Vitrectomy with rt-PA allows direct hemorrhage removal but is invasive with surgical risks. Treatment should be individualized based on hemorrhage size, location, duration, patient health, and visual goals. A multidisciplinary approach is recommended. The review underscores the need for larger, prospective RCTs to establish evidence-based guidelines. Ongoing research may refine existing therapies and introduce new modalities.