Management of subfoveal hemorrhage in age-related macular degeneration (AMD) is a challenging and difficult situation for the patient and the surgeon. How disheartening to look inside an eye to find a large clot of blood under the fovea, a small depression in the retina of the eye, particularly after other treatments have already been initiated. Such a clot is a sign of submacular hemorrhage and occult choroidal neovascularization (CNV).
Even worse is the devastating loss of vision for the patients, who carry an extremely poor prognosis. In this hopeful day of anti-vascular endothelial growth factor (VEGF) therapy, an easy fix for those patients with subretinal bleeds from AMD and devastating visual loss is yet to be found.
Part of the dilemma of finding a way to improve this condition is that these cases are infrequent. Another major factor in this disease process is time.
The blood is toxic to the retina and damage occurs early. Those patients whose hemorrhage was less than 14 days old had a twofold chance of visual improvement compared to those whose hemorrhage was 14 to 21 days old. None of the patients with blood under the macula for longer than 21 days improved vision.
Another consideration is that even with successful management of a submacular hemorrhage, the choroidal neovascular membrane and the disease process of AMD is not better. Even after the blood is cleared and the vision returns, patients may have further vision loss from recurrent CNV.
The debate continues: ethically, what should be done; financially does this make sense; and, in the end, will anything improve visual function? Of course not all submacular hemorrhages are created equal. They come in all shapes and sizes and depths. The available natural history studies did not classify the extent of hemorrhage in the small-case analysis. Presumably, small thin hemorrhage under the fovea most likely would have a far better prognosis than the dense choroidal hemorrhage with serous retinal detachment.
Current possible managements for subretinal hemorrhage include observation, treatments that do not address the damage from the hemorrhage, such as anti-VEGF medication or photodynamic therapy (PDT), and treatments that target removal of hemorrhage from the macula, such as submacular surgical extraction, pneumatic displacement with or without tissue plasminogen activator, lavage with perflurocarbon liquid, and macular translocation.>