Premacular hemorrhage is one major cause of sudden visual loss and occurs in a variety of disorders, among others in retinal arterial macroaneurysms (RAM). Possible therapeutic options include observation, vitrectomy, intravitreal rT-PA injection or laser posterior hyaloidotomy. However, the best treatment is still controversial. We report on 2 cases with premacular haemorrhage due to RAM. The first case was successfully treated with laser posterior hyaloidotomy and in the second case no treatment was applied.


Description and discussion of 2 clinical cases.


Case 1: A 57 year-old male with hypertension presented with a sudden and painless loss of vision in the right eye (RE). Visual acuity was light perception in the affected and 20/20 in the left eye (LE). Slit lamp biomicroscopy revealed a normal anterior segment in both eyes. Ophthalmoscopy of the RE showed a premacular haemorrhage and was completely normal in the LE. Three days after initial symptoms a posterior hyaloidotomy was performed with photodisruptive Nd: YAG laser. After consecutive vitreous hemorrhage had largely resorbed, fundus examination showed a RAM at the superotemporal artery which was confirmed by fluorescein angiography. Laser photocoagulation at the RAM site was carried out. Four months after posterior hyaloidotomy visual acuity in the RE had improved to 20/20, and the vitreous had cleared from hemorrhage completely.

Case 2: A 56 year-old woman presented with sudden and painless decrease in vision in her RE. Medical history was unremarkable. Best-corrected visual acuity was finger-counting in the RE and 20/20 in the LE. Fundus examination showed a premacular hemorrhage in the affected eye. The patient decided against specific therapy. Premacular hemorrhage resorbed spontaneously. Four months after initial presentation, visual acuity had improved to 20/20.


Premacular hemorrhage due to RAMs may cause a transient severe loss of vision, but can also cause permanent macular damage.

In case 1, successful posterior hyaloidotomy of the pre-retinal blood pocket was carried out to speed visual acuity recovery and minimize possible macular complications.

In case 2, no treatment was performed. In both cases visual acuity recovered to 20/20 after about 4 months.


Treatment for premacular hemorrhage remains controversial. Any treatment consideration must balance out the benefit/risk ratio and also take into account the patient′s decision. Specific approach to the causative RAM is only possible after the premacular hemorrhage has resorbed, either spontaneously or after intervention.