We present two different surgical approaches to address submacular hemorrhage.

Setting / Venue:

Department of Ophthalmology – Centro Hospitalar e Universitário de Coimbra, Portugal.


We present the cases of two patients with submacular hemorrhage that underwent 23-gauge pars plana vitrectomy (PPV) assisted by tissue plasminogen activator (t-PA) The first case refers to a 59 year-old woman, with high myopia who presented with sudden visual loss in her left eye (LE) for the previous 15 days. Her LE best corrected visual acuity (BCVA) was < 20 /400. At fundoscopic examination a submacular hemorrhage was present. An intravitreal ranimizumab injection was performed 3 days before 23-gauge PPV. After mechanical detachment of the posterior hyaloid and internal limiting membrane (ILM) peeling, t-PA (100ug) was applied over the macula. Fluid-air exchange was then performed. The second case refers to a 79 years-old woman, with diabetes mellitus type 2 and age-related macular degeneration. She complained of severe vision loss of her right eye (RE) for the previous month. RE BCVA was < 20/400. At fundoscopic examination she presented a massive submacula r hemorrhage. The surgical procedure consisted of a 23-gauge PPV and submacular injection of ranimizumab (0.5mg), t-PA (25ug) and 0.1 ml of filtered air with a 39-gauge microcannula. Fluid-air exchange was performed filling the eye with a non-expansile 20% sulfur hexafluoride (SF6) gas solution.


Optical coherence tomography (OCT) and angiography were performed pre and post-operatively in both cases and patients are currently in their third month of postoperative follow-up. Both patients improved their BCVA to 20/400, and anatomical success was accomplished.


Anatomical result was satisfactory in both cases, however functional improvement is not proportional to anatomical success. Possible explanations for this may be the presence of the clot in the subretinal space and the previous damage to the retina from the underlying disease. Submacular air injection with a microneedle may facilitate the displacement of dissolved clots by t-PA, which appears to be a safe and effective approach for submacular hemorrhage.

Contact Details:

Email: filipe.henriques.oftalmologia@gmail.com
Cell Phone: +351918362497

Filipe Henriques