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

BACKGROUND: Acute submacular hemorrhage (SMH) secondary to choroidal neovascularization (CNV), most commonly in neovascular age-related macular degeneration, is a vision-threatening emergency. Thick, fovea-involving SMH can cause rapid photoreceptor injury, and timely intervention aimed at clot lysis and displacement, while continuing CNV suppression with anti-vascular endothelial growth factor (anti-VEGF) therapy, may improve anatomic outcomes. CASE SUMMARY: We report a retrospective case series of three eyes with acute, fovea-involving CNV-related SMH treated with pars plana vitrectomy (PPV), subretinal tissue plasminogen activator (tPA), and expansile gas tamponade, with intravitreal anti-VEGF administered at the end of the procedure and continued postoperatively. Two cases had early intraocular pressure-related events (transient hypotony in one patient and transient ocular hypertension in another) requiring close postoperative monitoring and medical management. Follow-up color fundus photography and optical coherence tomography documented postoperative evolution of the hemorrhage compared with baseline, with ongoing anti-VEGF therapy planned to control the underlying CNV. CONCLUSION: PPV with subretinal tPA and gas tamponade is a practical surgical strategy for acute, thick, fovea-involving SMH secondary to CNV, particularly when rapid displacement is desired. Careful documentation of operative parameters, strict postoperative monitoring for pressure-related complications, and continued anti-VEGF therapy are essential components of care.