Large submacular hemorrhage (SMH) is a devastating complication of neovascular age-related macular degeneration (AMD) that cannot be effectively managed with anti-vascular endothelial growth factor injections alone. While SMH is not common, AMD patients with existing coagulopathies or taking anticoagulant medications are particularly susceptible. Today, various techniques are available for the management of SMH, including pneumatic displacement with or without intravitreal tissue plasminogen activator (tPA), pars plana vitrectomy with subretinal tPA and gas tamponade, and submacular surgery with vitrectomy and retinotomy for clot extraction. While no consensus exists, the preferred technique is often determined by the extent or duration of the hemorrhage and surgeon preference. This chapter reviews treatment options for managing SMH, as well as the current evidence for supporting their use.
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