ACUTE NEUROSENSORY RETINAL THINNING AND SHORT-TERM VISUAL OUTCOMES IN MASSIVE SUBMACULAR HEMORRHAGE: A LONGITUDINAL ANALYSIS FROM PRE-ONSET TO POST-DISPLACEMENT WITH SUBRETINAL TISSUE PLASMINOGEN ACTIVATOR

PURPOSE: To investigate longitudinal visual and structural changes from pre-onset to 1 month postoperatively in eyes with massive submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD) treated with subretinal tissue plasminogen activator (tPA) injection and to identify prognostic factors for visual outcomes. METHODS: This retrospective observational study reviewed the medical records of consecutive eyes with massive SMH secondary to nAMD treated with pars plana vitrectomy with subretinal tPA injection and pneumatic displacement. We assessed best-corrected visual acuity (BCVA) and foveal sensory retinal thickness (FSRT) at pre-onset, preoperative, and 1-month postoperative time points. RESULTS: Among 74 consecutive eyes treated with subretinal tPA injection for massive SMH, we analyzed 20 eyes with available pre-onset data. FSRT decreased significantly from 193.5 ± 101.4 μm at pre-onset to 107.0 ± 59.0 μm at 1 month postoperatively (P < 0.001). BCVA change negatively correlated with FSRT change (r = -0.56, P = 0.01). Univariable analysis showed that pre-onset BCVA significantly correlated with 1-month BCVA (r = 0.45, P = 0.049). At pre-onset, persistent fluid and pigment epithelial detachment were present in 65% and 15%, respectively. CONCLUSIONS: Massive SMH causes acute and profound neurosensory retinal thinning, and pre-onset neuronal integrity may be a key determinant of visual outcomes. Because surgery cannot reverse this immediate damage, preventing hemorrhage by maintaining a strictly fluid-free macula may be an important proactive strategy.