Displacement of submacular haemorrhage – comparative study pneumatic displacement versus subretinal cocktail injection
Reviewed by Sofia Rokerya

The authors report a multicentre retrospective interventional case series study comparing the outcome of submacular haemorrhage (SMH) using pneumatic displacement with intravitreal expansile gas versus treatment with pars plana vitrectomy (PPV) versus subretinal injection of tissue plasminogen activator (tPA), anti-vascular endothelial growth factor (anti-VEGF) agent, and air as primary surgery. Medical records of patients who underwent interventional displacement of SMH secondary to neovascular age-related macular degeneration (nAMD) or polypoidal choroidal vasculopathy (PCV) were reviewed for data on diagnosis, dermographics, medical and ophthalmic history, logMAR visual acuity (VA), central subfield thickness (CST), postoperative displacement rates and postoperative complications for up to 12 months. Out of the 63 eyes included in the study 24 (38.1%) eyes were diagnosed to have nAMD and 39 (61.9%) eyes PCV. Forty (63.5%) eyes underwent pneumatic displacement (38 of these received C3F8 whereas two eyes received SF6). Eight (42.1%) and five (12.5%) eyes underwent concomitant intravitreal anti-VEGF and tPA injection, respectively. Twenty-three (36.5%) eyes were in the subretinal cocktail injection group. There was no statistically significant difference in patients’ demographics between the two groups, such as mean age and gender. However, the pneumatic displacement group had a larger proportion of eyes with PCV (72.5% vs 43.5%, p=0.032), less extensive SMH (p=0.005), shorter duration between symptom onset and surgery (5.46 vs 10.65 days, p=<0.001), and thinner baseline CST (780.2μm vs 1006.6μm, p=0.012). The subretinal injection group had more extensive SMH (p=0.005), thicker CST (1006.6μm vs 780.2μm, p=0.012), and longer interval between symptom and operation (10.65 vs 5.53 days, p<0.001). Mean baseline VA was 1.46 and 1.62 logMAR, respectively (p=0.404). The mean postoperative VA at six months was 0.67 and 0.91 (p=0.180) for pneumatic displacement and subretinal injection groups, respectively. VA was significantly better in the pneumatic group at 12 months (0.64 vs 1.03, p=0.040). At least 10 mean change in VA were >10 letters gain in both groups up to 12 months. Postoperative CST reduction was greater (625.1μm vs 326.5μm, p=0.008) and complete foveal displacement (87.0% vs 37.5%), p<0.001, odds ratio [OR] = 11.1) and displacement to arcade or beyond (52.5% vs 17.5%, p=<0.001, OR = 5.15) were more frequent in the subretinal cocktail injection group. The mean number of anti-VEGF within the first year was similar between the two groups (p=0.305), which was 3.10 and 2.70 for the pneumatic displacement and subretinal injection group, respectively. Postoperative verteporfin photodynamic therapy was more commonly performed in the pneumatic displacement group, but the difference was not statistically significant (25.0% vs 8.7%, p=0.183) There was no statistically significant difference in the rate of postoperative SMH recurrence, vitreous haemorrhage, hyphaemia, intraocular pressure spike, or retinal detachment. The pneumatic displacement group had higher reoperation rate (20% vs 12.0%), but the difference was not statistically significant (p=0.732). Surgical displacement of SMH leads to clinically meaningful improvement in VA. The conclusion drawn was that PPV with subretinal cocktail injection is more effective than pneumatic displacement in displacing SMH with similar safety profile despite longer interval before operation, higher CST, and more extensive SMH at baseline. Limitations: Retrospective, small sample size, differences in baseline characteristics between the two groups, selection bias, lack of standardised post-op anti-VEGF protocol.

Displacement of submacular hemorrhage using subretinal cocktail injection versus pneumatic displacement: a real-world comparative study.
Szeto SKH, Tsang CW, Mohamed S, et al.
OPHTHALMOLOGICA
2024;247:118–31.