Predictors of 1-Year Visual Outcome in Central-Involving Submacular Hemorrhage Secondary to Neovascular AMD

Overview

Submacular hemorrhage (SMH) is a sight-threatening complication of neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV). It occurs when blood accumulates under the macula, the central part of the retina responsible for sharp, detailed vision. When the fovea is involved, vision can decline rapidly because this area is essential for reading, recognizing faces, and seeing fine detail.

This study evaluated which clinical and imaging features can help predict visual recovery 12 months after treatment in Asian patients with central-involving SMH caused by nAMD or PCV. The findings are clinically important because they may help retina specialists counsel patients more accurately and tailor treatment strategies earlier in the course of disease.

Why this condition matters

In SMH, blood can damage the retina through several mechanisms: toxic effects from iron and other blood breakdown products, physical separation of retinal layers, and disruption of the photoreceptors and retinal pigment epithelium. The longer the blood remains under the fovea, the greater the risk of permanent vision loss. For this reason, SMH is generally treated urgently.

In Asian populations, PCV is a particularly common cause of SMH. Although nAMD and PCV are both forms of abnormal blood vessel growth beneath the retina, PCV often behaves differently and may present with more bleeding. Understanding predictors of outcome in this mixed patient population is therefore especially relevant in Asia.

Study design and patients

This was a prospective observational clinical cohort study conducted between January 2016 and July 2024. The investigators reviewed treatment-naïve eyes that presented with fovea-involving SMH measuring at least 1 disc diameter, with no signs that the blood had already organized.

A total of 487 untreated eyes were initially considered. Of these, 75 eyes met the inclusion criteria. The average age was 71.4 years, and 74.4% of the patients were men. Most eyes, 76.0%, had PCV rather than classic nAMD.

The mean hemorrhage size was 18.92 mm², though there was wide variation, indicating that some eyes had relatively limited bleeding while others had extensive hemorrhage.

Treatment approach

All eyes received anti-vascular endothelial growth factor (anti-VEGF) therapy, which is the standard treatment for nAMD and PCV. Anti-VEGF injections help suppress the abnormal vessels responsible for leakage and bleeding.

A small number of eyes received additional procedures: 2.6% underwent pneumatic displacement, a technique that uses an intravitreal gas bubble to help move blood away from the fovea, and 5.3% received photodynamic therapy (PDT), a treatment that activates a light-sensitive drug to reduce abnormal choroidal vessels.

Because treatment was individualized as part of routine care, the study reflects real-world management rather than a single rigid protocol.

Visual outcomes at 12 months

Best-corrected visual acuity (BCVA) improved overall from 1.04 logMAR at baseline to 0.69 logMAR at 12 months. This represents meaningful average visual improvement, although many patients still had significant visual impairment.

At one year:
– 25 eyes (33.3%) achieved a good visual outcome, defined as 0.3 logMAR or better, approximately equivalent to 20/40 vision or better.
– 22 eyes (29.3%) had a poor visual outcome, defined as 1.0 logMAR or worse.

These results show that visual recovery after SMH is possible, but the final outcome varies substantially from patient to patient.

Key predictors of good vision

The study identified three factors independently associated with a good visual outcome at 12 months:

1. Younger age
Patients who were younger were more likely to recover better vision. In practical terms, for each additional decade of age, the odds of a good outcome decreased.

2. Better baseline BCVA
Eyes that already had relatively better vision at presentation were more likely to end up with better vision at one year. This is consistent with the idea that less initial retinal damage gives the eye a greater chance of recovery.

3. Thicker subfoveal choroid
A thicker choroid beneath the fovea was associated with a better visual outcome. The choroid is the vascular layer beneath the retina, and its thickness may reflect the underlying disease subtype and tissue condition. In this study, choroidal thickness emerged as a potential biomarker that may help predict prognosis.

Predictors of poor vision

Larger hemorrhage size was associated with a poor visual outcome. This makes biological sense: larger bleeds are more likely to cause extensive damage to the photoreceptors and retinal pigment epithelium, and blood may remain under the fovea longer or be more difficult to displace.

The study therefore reinforces a key clinical message: the size and severity of hemorrhage matter, not just the presence of bleeding itself.

What the findings mean for clinicians

These results provide a practical framework for counseling patients with central-involving SMH from nAMD or PCV. In general, a younger patient with better starting vision, a smaller hemorrhage, and a thicker subfoveal choroid may have a more favorable prognosis.

For retina specialists, the findings also highlight the value of multimodal imaging. Optical coherence tomography (OCT), and where available other imaging modalities such as indocyanine green angiography, can help assess hemorrhage extent, choroidal features, and the type of underlying maculopathy.

Although anti-VEGF therapy remains the foundation of treatment, some patients may benefit from combination approaches such as pneumatic displacement or PDT depending on the location and extent of bleeding, lesion characteristics, and the treating physician’s judgment.

Clinical interpretation and limitations

This study adds to the growing evidence that not all SMH cases have the same prognosis. The presence of PCV in most patients is also notable, since PCV is common in Asian populations and may have a different hemorrhagic profile than typical nAMD.

However, several limitations should be kept in mind. The sample size was modest, especially after applying strict inclusion criteria. Treatment was not uniform across all eyes, which reflects real-world practice but can introduce variability. Also, the study focused on an Asian cohort, so the findings may not fully generalize to other populations.

Despite these limitations, the prospective design and one-year follow-up strengthen the clinical relevance of the results.

Bottom line

About one-third of eyes with fovea-involving submacular hemorrhage reached 0.3 logMAR vision (roughly 20/40) or better after treatment. Younger age, better baseline vision, and thicker subfoveal choroid predicted better outcomes, while larger hemorrhage size predicted worse outcomes.

For patients and clinicians alike, the message is clear: early assessment and prompt treatment are crucial, and detailed imaging may help estimate the chance of visual recovery more accurately.