Smiley-Shaped Posterior Retinotomy for Large SMH

A large, submacular hemorrhage (SMH) is a vision-threatening condition commonly associated with wet AMD, although it may also arise from polypoidal choroidal vasculopathy, myopic choroidal neovascularization, retinal arterial macroaneurysm, trauma, inflammatory choroidal neovascular membranes, or idiopathic causes (Figures 1-4). Experimental studies have demonstrated that rapid photoreceptor injury can occur from subretinal blood due to iron toxicity, mechanical disruption, and impaired metabolic exchange.^1,2

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Figure 1. Preoperative fundus photography showed confluent drusen at the posterior pole consistent with Doyne honeycomb dystrophy and a medium-sized subretinal hemorrhage due to active macular neovascularization (A). OCT imaging showed drusenoid pigment epithelial detachments with subretinal fluid and subretinal hyperreflective material, consistent with hemorrhage (B).

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Figure 2. Postoperative fundus photography demonstrated a smiley-shaped posterior retinotomy placed at the area of maximal clot thickness and away from the fovea, with associated subretinal fibrosis (A). OCT imaging demonstrated complete resolution of subretinal fluid with restoration of foveal contour and focal nasal disruption of the ellipsoid zone (B).

Although pneumatic displacement with intravitreal tissue plasminogen activator (tPA) and expansile gas is the most widely used treatment, with select cases also benefiting from subretinal tPA administration to facilitate more direct clot lysis and displacement, outcomes may be suboptimal for large, thick, and/or organized hemorrhages.^3-7

We describe a modified curved (“smiley-shaped”) posterior retinotomy technique for direct clot evacuation and report 6-month anatomical and functional outcomes in a consecutive case series of 11 eyes with large SMH (Table).

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SURGICAL TECHNIQUE

All eyes underwent standard pars plana vitrectomy. Triamcinolone acetonide was used to facilitate and confirm posterior vitreous detachment. Following core and peripheral vitrectomy, a curved posterior retinotomy was fashioned adjacent to the hemorrhage in an area of maximal clot thickness and away from the fovea, allowing controlled access to the subretinal space without direct foveal manipulation.

The vitrectomy cutter was gently introduced through the retinotomy, and the submacular clot was engaged under high vacuum and carefully aspirated. Infusion pressure was transiently elevated to 60 mm Hg during clot evacuation to reduce intraoperative bleeding and subsequently lowered to address any active bleeding.

Perfluorocarbon liquid was then injected to stabilize and flatten the posterior pole, followed by focal laser photocoagulation at the retinotomy site, fluid-air exchange, and C₃F₈ gas tamponade. This approach is based on principles previously described for surgical drainage of SMH and the use of subretinal tPA and perfluorocarbon liquids.^8-11

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Figure 3. Preoperative fundus photography demonstrated a large subretinal hemorrhage consistent with idiopathic polypoidal choroidal vasculopathy (A). The postoperative fundus photograph demonstrated complete evacuation of the subretinal hemorrhage via smiley-shaped retinotomy with surrounding laser photocoagulation marks and adjacent fibrosis (B).

RESULTS

Thirteen consecutive eyes with fovea-involving SMH (symptom duration of 2 to 12 days) were included. Four eyes had received prior intravitreal tPA 24 hours before surgery. Preoperatively, the mean BCVA was 1.78 ± 0.28 logMAR (approximately 20/1,200; range 20/660 to 20/90). The mean central macular thickness (CMT) was 589 ± 147 µm, and OCT imaging showed dense, hyperreflective subfoveal hemorrhage with foveal elevation in each eye.

At 6 months postoperative, mean BCVA improved to 0.52 ± 0.31 logMAR (approximately 20/66; mean gain 1.26 logMAR units; range 20/200 to 20/30), and mean CMT decreased to 232 ± 51 µm. OCT demonstrated complete hemorrhage clearance with restored foveal contour in seven eyes, restored contour with residual thinning in two eyes, and residual subretinal fibrosis in three eyes.

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Figure 4. Preoperative fundus photography demonstrated a large subretinal hemorrhage secondary to active choroidal neovascular membrane in wet AMD (A). Postoperative fundus photography demonstrated the site of the smiley-shaped retinotomy with evacuation of the subretinal hemorrhage and minimal residual subretinal fibrosis (B).

Eyes with complete anatomical restoration achieved superior visual outcomes. No cases of retinal detachment, recurrent hemorrhage, or persistent submacular blood were observed. 

A GOOD OPTION IN SELECT CASES

Pneumatic displacement with intravitreal tPA and gas remains the preferred first-line approach for many cases of SMH.^3-5 However, in large, thick, and/or organized hemorrhages, incomplete clot liquefaction and displacement may limit visual recovery.^6,7

Direct surgical evacuation through a posterior retinotomy offers immediate clot removal, avoids dependence on postoperative positioning, and facilitates rapid anatomic restoration.^8-10 The curved or “smiley-shaped” retinotomy described in this series enables controlled access to the subretinal space while minimizing retinal trauma and preserving foveal integrity.

The significant reduction in CMT and restoration of foveal contour on OCT closely paralleled visual improvement, reinforcing a strong structure-function correlation. Residual subretinal fibrosis was associated with comparatively poorer outcomes, underscoring the importance of early intervention before irreversible photoreceptor damage occurs.

Although limited by its retrospective design and modest sample size, the study showed consistent anatomical and functional improvements, suggesting that this technique represents a valuable alternative approach in selected cases of large SMH. 

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2. Hochman MA, Seery CM, Zarbin MA. Pathophysiology and management of subretinal hemorrhage. Surv Ophthalmol. 1997;42(3):195-213.

3. Hassan AS, Johnson MW, Schneiderman TE, et al. Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement. Ophthalmology. 1999;106(10):1900-1906. 

4. van Zeeburg EJT, van Meurs JC. Literature review of recombinant tissue plasminogen activator used for recent-onset submacular hemorrhage displacement in age-related macular degeneration. Ophthalmologica. 2013;229(1):1-14.

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9. Kamei M, Tano Y, Maeno T, Ikuno Y, Mitsuda H, Yuasa T. Surgical removal of submacular hemorrhage using tissue plasminogen activator and perfluorocarbon liquid. Am J Ophthalmol. 1996;121(3):267-275.

10. Gibran SK, Romano MR, Wong D. Surgical management of massive submacular hemorrhage associated with age-related macular degeneration. Retin Cases Brief Rep. 2009 Fall;3(4):391-394.

11. Ozkaya A, Erdogan G, Tarakcioglu HN. Submacular hemorrhage secondary to age-related macular degeneration managed with vitrectomy, subretinal injection of tissue plasminogen activator, hemorrhage displacement with liquid perfluorocarbon, gas tamponade, and face-down positioning. Saudi J Ophthalmol. 2018;32(4):269-274.