We read with great interest the recent article by Chang and associates. The authors concluded that vitrectomy with subretinal tissue plasminogen (t-PA) injection and gas tamponade was found to be effective for displacement of thick submacular hemorrhage. We have conducted a similar study in our institution (Sherman M, et al. IOVS 2013; 54:ARVO E-Abstract 3304), which was presented in part at The Association for Research in Vision and Ophthalmology in 2013.

Submacular hemorrhage associated with age-related macular degeneration (AMD) is a rare event. It is important to have a control group for comparison to determine the best treatment option. Numerous factors, which were not controlled for in the study, would directly influence treatment outcomes, such as duration of submacular hemorrhage, depth/height and size of the submacular hemorrhage, and the location of subretinal choroidal neovascular membrane in related to the fovea. Lewis showed that submacular hemorrhage with duration greater than 7 days was associated with poor visual outcomes. Other studies have shown that amount or severity of subretinal hemorrhages were negatively correlated with visual outcomes. Obviously, the presence of a choroidal neovascular membrane involving the fovea would be expected to have worse visual prognosis compared to a choroidal neovascular membrane that is extrafoveal.

In the study at our institution we compared functional and anatomic outcomes of treatment of submacular hemorrhage associated with age-related macular degeneration between 3 groups of patients: patients who were treated with intravitreal tPA, patients who were treated with vitrectomy and subretinal tPA, and patients who were treated with pneumatic displacement alone. Our results showed that treatment with tPA (subretinal or intravitreal) improves the functional and anatomic outcomes in patients with submacular hemorrhage attributable to exudative AMD, in comparison to pneumatic displacement alone. Vitrectomy with subretinal tPA was anatomically but not visually superior to intravitreal tPA with a significant reduction in the size of the final macular scar.

We congratulate Chang and associates for this important report and look forward to larger comparative randomized studies that will help us determine optimal treatment protocols in this patient population.