Current management of subretinal hemorrhage in neovascular age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of irreversible vision loss among individuals aged 65 years and older in the United States. For individuals diagnosed with age-related macular degeneration (AMD), approximately 12% experience varying levels of subretinal hemorrhage (SRH), which can be further classified by size into small, medium, and massive measured in disc diameters. SRH are an acute and rare sight-threatening complication characterized by an accumulation of blood under the retina arising from the choroidal or retinal circulation. Released iron toxins, reduced nutrient supply, fibrin meshwork contraction, and outer retinal shear forces created by SRH contribute to visual loss, macular scarring, and photoreceptor damage. SRH treatment strategies aim to displace hemorrhage from the foveal region and prevent further bleeding. Although there are no standardized treatment protocols for SRH, several surgical and non-surgical therapeutical approaches may be employed. The most common surgical approaches that have been utilized are pars plana vitrectomy (PPV) combined with multiple maneuvers such as the removal of choroidal neovascularization (CNV) lesions, macular translocation, retinal pigment epithelium (RPE) patch repair, SRH drainage, intravitreal injection of recombinant-tissue plasminogen activator (tPA), expansile gas and air displacement, and anti-vascular endothelial growth factor (anti-VEGF) injections. Non-surgical therapeutical approaches include intravitreal anti-VEGF monotherapy, intravitreal t-PA administration without PPV, and photodynamic therapy (PDT). This review article aims to explore the current treatment strategies and supporting literature regarding both surgical and non-surgical, of SRH in patients with AMD. Moreover, this article also aims to highlight the distinct treatment modalities corresponding to different sizes of SRH.