We appreciate Dr Kishore’s interest in our recently published manuscript. He questioned the use of bevacizumab (1.25 mg/0.05 mL; Avastin; Genentech Inc, San Francisco, California, USA) for the treatment of subfoveal hemorrhage secondary to retinal arterial macroaneurysm and stated that it has limited benefits. We agree that bevacizumab monotherapy could be insufficient for submacular hemorrhage treatment. He noted that in our study, 2 (Patients 10 and 12) out of 4 patients with submacular hemorrhage showed poor visual outcomes after bevacizuamb injections. However, there were also patients with good visual outcomes in spite of submacular hemorrhage after treatment. In our study, in 2 patients (Patients 14 and 19) with submacular hemorrhage, the visual acuity increased by more than 0.3 logarithm of the minimal angle of resolution (logMAR) after treatment. To date, the precise treatment effects or anti–vascular endothelial growth factor mechanisms for submacular hemorrhage have not yet been clearly elucidated. Various factors, including symptom duration, submacular hemorrhage size, or subfoveal hemorrhage thickness, could be associated with the efficacy of bevacizumab injection for the submacular hemorrhage. The factors associated with a good visual outcome after bevacizumab injection for patients with submacular hemorrhage require further investigation.

Dr Kishore mentioned that recombinant tissue plasminogen activator (rTPA) may be effective in retinal arterial macroaneurysm treatment. However, the minimum safe concentration and retinal toxicity of rTPA is still controversial. Moreover, some reports suggest that cases with submacular hemorrhage secondary to retinal arterial macroaneurysm have an increased risk of dense vitreous hemorrhage after intravitreal rTPA injection. Furthermore, if combined with vitrectomy, the surgical approach could induce various complications, more than those in the case of an intravitreal injection administration. In our opinion, in spite of its lysis efficacy and ability to clear subretinal clots, the use of rTPA for retinal arterial macroaneurysm should be carefully considered. A less invasive and safer treatment modality might be preferred for the management of retinal arterial macroaneurysm. The best method for management of retinal arterial macroaneurysm is yet to be determined. Therefore, a planned randomized controlled study would be necessary.