Surgical management of acute choroidal neovascularization related submacular hemorrhage: Three case reports

Table 1 Summary of cases

Variable	Case 1	Case 2	Case 3
Age/sex	73/M	87/M	89/M
Eye	OD	OS	OS
CNV context	nAMD suspected/treated	nAMD treated (serial IV bevacizumab)	nAMD treated (serial IV aflibercept)
Acute presentation (VA + finding)	CF @ approximately 1 m, subretinal bleed	CF @ approximately 50 cm, subretinal bleed	LP, subretinal bleed
Intervention	OR-based displacement procedure (PPV + subretinal tPA + gas per protocol)	PPV + subretinal tPA + gas	PPV + subretinal tPA + gas
VA course (early follow-up)	Pre-op: CF @ 1 m → POD1: CF @ 1 m → POW2: CF @ 1.5 m → POW3: HM	Pre-op: CF @ 50 cm → POD1: CF near face → POD10: CF < 1 m	Pre-op: LP → POD1: CF @ 1 m → POD8: HM
Early postop issue	Hypotony (IOP 2 on POD2)	Ocular hypertension (IOP 27 on POD1)	None
Anti-VEGF	Planned/ongoing	Continued/ongoing	Planned/ongoing
Follow-up duration	6 months	12 months	6 months

CNV: Choroidal neovascularization; OD: Oculus dexter; OS: Oculus sinister; CF: Counting fingers; VA: Visual acuity; LP: Light perception; PPV: Pars plana vitrectomy; tPA: Tissue plasminogen activator; Anti-VEGF: Anti-vascular endothelial growth factor; OR: Operating room.

Table 2 Proposed algorithm for acute choroidal neovascularization related submacular hemorrhage

Hemorrhage characteristics	Recommended management
Small, thin hemorrhage (< 1-2 disc diameters, < approximately 100 µm thick on OCT) not affecting fovea, early presentation	Anti-VEGF therapy alone (intravitreal injections) is usually sufficient. Consider adding pneumatic displacement (gas injection) for faster clearance if hemorrhage overlies near-foveal area. Monitor closely on anti-VEGF; many will improve without surgery
Moderate hemorrhage (approximately 2-5 DD in area or 100-500 µm thick) with foveal involvement, onset < approximately 14 days, predominantly subretinal (not sub-RPE)	Displacement therapy indicated. If patient is a good candidate, perform PPV with subretinal tPA + gas tamponade for maximal clearance. Alternatively, an initial intravitreal tPA + gas (office procedure) may be attempted, especially if surgical timing is an issue. In either case, prompt anti-VEGF is given (at time of procedure or shortly after) to treat CNV
Large hemorrhage (> 5 DD, or any causing hemorrhagic retinal detachment), very thick (> 500 µm on OCT), or persistent after less invasive treatment	Pars plana vitrectomy is recommended. Use subretinal tPA to liquefy clot; expect to perform a larger retinotomy in cases of hemorrhagic detachment. Consider mechanically evacuating clot and CNV if it’s massive. Gas tamponade often used; for very extensive detachments, use longer-acting gas or even silicone oil if needed. Follow with intensive anti-VEGF therapy. Visual prognosis is guarded but intervention may still improve outcomes vs observation
Chronic or sub-RPE hemorrhage (duration > 2-3 weeks, blood appears yellow on exam indicating older clot; or primarily sub-RPE location on OCT)	Conservative approach often advised. Surgical or pneumatic displacement is less effective once blood has organized (high fibrin). Treat underlying CNV with anti-VEGF; consider observing or applying photodynamic therapy (for PCV) if applicable. If visual potential is still significant and hemorrhage is thick, a case-by-case decision for surgery can be made, but counsel that visual improvement is less likely

CNV: Choroidal neovascularization; PPV: Pars plana vitrectomy; tPA: Tissue plasminogen activator; Anti-VEGF: Anti-vascular endothelial growth factor; OCT: Optical coherence tomography; sub-RPE: Sub–retinal pigment epithelium; PCV: Polypoidal choroidal vasculopathy.