Macular Hemorrhages in AMD: When Urgent Care Matters
Understanding Macular Hemorrhages
A submacular hemorrhage occurs when blood collects between the light-sensing layer of the retina (the neurosensory retina) and the retinal pigment epithelium (RPE). The RPE is the supportive tissue layer beneath the retina. The macula is the small central area of the retina responsible for sharp, detailed vision. When blood pools here, it can block the macula from working properly and threaten severe vision loss.
This type of hemorrhage is most commonly linked to neovascular age-related macular degeneration (wet AMD). In wet AMD, abnormal blood vessels grow beneath the retina and leak fluid or blood. Other possible causes include polypoidal choroidal vasculopathy (PCV), pathologic myopia, ruptured retinal artery macroaneurysms, and eye trauma.
Blood beneath the macula damages the photoreceptors (the cells that detect light) through several mechanisms. First, the blood clot blocks the normal exchange of nutrients and waste between the retina and the RPE. Without this exchange, the photoreceptors are starved of the support they need to survive.
Second, the fibrin network within the blood clot can pull on and physically damage delicate photoreceptor cells. Third, as the blood breaks down, iron from hemoglobin triggers harmful molecules called free radicals. These free radicals cause oxidative damage to the surrounding tissue. Together, these effects can lead to rapid and irreversible photoreceptor loss. If left untreated, the blood clot typically turns into scar tissue, resulting in lasting vision loss.
Wet AMD is the most common cause of submacular hemorrhage. In wet AMD, the body produces too much vascular endothelial growth factor (VEGF). This protein stimulates abnormal blood vessel growth beneath the retina. These fragile new vessels are prone to leaking fluid and blood. When a significant bleed occurs, blood can spread beneath the macula and cause a sudden drop in central vision.
An estimated many millions Americans were living with some form of AMD in 2019, with approximately several million having late-stage, vision-threatening AMD (NORC/University of Chicago, 2019). Although submacular hemorrhage is not common among all AMD patients, it represents one of the most urgent complications of the wet form of the disease.
Who Is Affected and Risk Factors
Submacular hemorrhage most frequently affects older adults with existing wet AMD. Research analyzing over 140,000 eyes found that ages between 65 and 90 were associated with increased odds of developing a submacular hemorrhage (Cardoso et al., PMC, 2022). People who have already been diagnosed with wet AMD carry the highest risk. However, the hemorrhage can also be the first sign of the disease.
In one study, submacular hemorrhage occurred in 36 percent of patients who had not yet received any treatment for wet AMD (Stanescu-Segall et al., PMC, 2022). This means a sudden hemorrhage can be the event that leads to an initial AMD diagnosis.
Patients taking antiplatelet or anticoagulant medications (blood thinners) face a significantly higher risk of macular hemorrhage. Research found that 63.5 percent of patients taking daily blood thinners experienced hemorrhage. This compared with 29.2 percent of patients not taking these medications. The odds ratio was 4.21, meaning the risk was more than four times higher (Stanescu-Segall et al., PMC, 2022).
If you take blood thinners for heart disease, stroke prevention, or another condition, discuss this risk with your retina specialist. Stopping blood thinners without medical guidance can be dangerous. This decision should involve both your retina specialist and the doctor who prescribed the medication.
Among patients already receiving anti-VEGF injections for wet AMD, submacular hemorrhage can still occur. In one study, 45 percent of affected patients had been on a stable injection schedule. Twelve percent had a recently extended interval between injections, and 7 percent had a shortened interval (Stanescu-Segall et al., PMC, 2022). Even patients under active treatment remain at risk.
Recurrence is also a concern. A study evaluating recurrent submacular hemorrhage in wet AMD found a recurrence rate of 51.1 percent over a mean follow-up period of approximately 37 months (Kim et al., PMC, 2015). Ongoing monitoring and consistent treatment are essential to reduce the chance of repeated hemorrhages.
Signs and Symptoms
The hallmark symptom of a submacular hemorrhage is sudden and severe vision loss in the affected eye. Many patients experience a dramatic decline to visual acuity of 20/200 or worse. This level is considered legal blindness. The vision loss typically occurs without pain. However, any sudden loss of central vision is an emergency.
In addition to central vision loss, patients may notice several other symptoms:
- A dark or blank spot in the center of vision
- Distortion of straight lines, where they appear wavy or bent
- A sudden increase in floaters (small dark shapes drifting across the visual field)
- In rare cases, more generalized peripheral vision loss if blood breaks through into the vitreous cavity
If you experience sudden vision loss, a dark spot in your central vision, or a sudden increase in floaters, see a retina specialist or go to the emergency room immediately. Blood under the macula begins damaging photoreceptors within hours. Earlier intervention is generally associated with better outcomes. In the Submacular Surgery Trial, only 11 percent of observation-group patients achieved visual acuity better than 20/200 at 24 months (Submacular Surgery Trials Research Group). Larger and thicker hemorrhages are linked to worse visual outcomes.
Diagnosis and Testing
A retina specialist will begin with a dilated eye exam. Special lenses and bright light are used to examine the back of the eye. A submacular hemorrhage typically appears as a dark red or brownish area beneath the central retina. The size, thickness, and location of the hemorrhage help guide treatment decisions.
Advanced imaging plays a critical role in evaluating submacular hemorrhage. Optical coherence tomography (OCT) uses light waves to create detailed cross-sectional images of the retina. OCT reveals the exact location of blood relative to retinal layers. It also measures hemorrhage thickness and detects associated fluid.
Fluorescein angiography (FA) involves injecting a special dye into a vein in the arm. The dye is photographed as it travels through the retinal blood vessels. This test helps identify the leaking abnormal vessels that caused the hemorrhage. Indocyanine green angiography (ICG) may also be used to evaluate deeper choroidal blood vessels. ICG is particularly helpful for diagnosing polypoidal choroidal vasculopathy.
Because submacular hemorrhage can result from several conditions, the retina specialist will identify the underlying cause. In most older adults, wet AMD is the primary suspect. However, imaging and clinical findings may point to other causes such as PCV, a ruptured macroaneurysm, or trauma. Identifying the correct cause is essential because it directly affects the treatment approach.
Treatment Options
Anti-VEGF injections are a cornerstone of treatment for wet AMD and submacular hemorrhage. These medications block the VEGF protein that drives abnormal blood vessel growth. Common anti-VEGF agents include:
- Eylea (aflibercept), typically given every 4 to 8 weeks after an initial loading period
- Lucentis (ranibizumab), typically given every 4 weeks
- Avastin (bevacizumab), which is FDA-approved for cancer and used off-label for eye conditions, typically given every 4 to 6 weeks
- Vabysmo (faricimab), a bispecific antibody given every 4 to 16 weeks after loading doses
- Eylea HD (high-dose aflibercept), which may allow longer intervals between injections
For smaller hemorrhages, anti-VEGF monotherapy may be enough to stop bleeding, promote blood resorption, and stabilize vision. Larger hemorrhages often require additional interventions.
Pneumatic displacement is a less invasive approach. A retina specialist injects an expansile gas bubble, often sulfur hexafluoride (SF6), into the vitreous cavity. The gas bubble pushes blood away from the center of the macula, allowing the underlying photoreceptors to recover. This technique can be combined with tissue plasminogen activator (tPA), a clot-dissolving enzyme that helps liquefy the blood.
After this procedure, you are typically asked to maintain a specific face-down or seated head position. This keeps the gas bubble in the correct location. Research has shown that pneumatic displacement combined with anti-VEGF therapy can lead to meaningful vision improvements without the risks of more invasive surgery.
For larger or thicker hemorrhages, a retina specialist may recommend pars plana vitrectomy (PPV). This is a surgery to remove the vitreous gel from inside the eye. During the procedure, the surgeon can access the area beneath the retina and inject tPA to dissolve the blood clot. An air or gas bubble is placed inside the eye to help flatten the retina and aid healing.
Some surgeons also deliver anti-VEGF medication directly beneath the retina during surgery. The NATIVE Study compared subretinal versus intravitreal delivery of Eylea (aflibercept) during vitrectomy for submacular hemorrhage caused by AMD. Both approaches achieved similar visual outcomes. However, patients receiving subretinal aflibercept required significantly fewer follow-up injections over 24 months (NATIVE Study).
Research comparing surgery to pneumatic displacement found that surgery did not yield superior visual gain at three months. Both groups also received intravitreal anti-VEGF injections. Both strategies led to clinically meaningful improvements over six months without significant safety concerns (Stanescu-Segall et al., PMC, 2022). The choice depends on hemorrhage size, patient health, and clinical judgment.
What to Expect
If you receive a pneumatic displacement procedure, it is usually performed in the office with numbing drops and a local anesthetic. The injection itself takes only a few minutes. You may need to maintain a specific head position for several days to keep the gas bubble over the macula.
If vitrectomy surgery is recommended, it is typically performed in an operating room under local or general anesthesia. The surgery usually takes 30 to 90 minutes. A gas bubble placed inside the eye will gradually dissolve over weeks. During this time, you cannot fly in an airplane or undergo certain types of anesthesia due to pressure changes.
Visual recovery after treatment varies significantly. Some improvement may be noticeable within the first few weeks as blood is displaced or absorbed. Full visual recovery, to whatever degree it will occur, may take several months. The final outcome depends on how long blood was under the macula before treatment, the hemorrhage size, and whether photoreceptor damage occurred before intervention.
Regardless of the initial procedure, ongoing anti-VEGF injections are needed to manage the underlying wet AMD. Without continued treatment, abnormal blood vessels are likely to regrow and leak again. Your retina specialist will determine the appropriate injection schedule based on your response to treatment and imaging findings at follow-up visits.
Living with Macular Hemorrhage Risk
If you have wet AMD, regular self-monitoring is one of the most important things you can do. An Amsler grid is a simple tool with a pattern of straight lines. Hold it at reading distance, cover one eye, and look at the center dot. If any lines appear wavy, broken, or missing, contact your retina specialist promptly.
Get into the habit of checking each eye separately every morning. Changes detected early provide the best chance for effective treatment.
If you take blood thinners, make sure your retina specialist knows about all medications you are using. Blood thinners serve important purposes for heart and vascular health. Your retina specialist needs this information to properly assess hemorrhage risk and coordinate with your prescribing physician.
Missing or delaying anti-VEGF injection appointments can increase the risk of disease progression and hemorrhage. Even when vision seems stable, the injections work to keep abnormal blood vessels in check. Skipping treatments can allow these vessels to become active again. If scheduling is difficult, discuss alternative arrangements or extended-dosing options with your retina specialist.
When to See a Retina Specialist
Seek immediate care from a retina specialist or go to the emergency room if you experience any of the following:
- Sudden, severe loss of central vision in one eye
- A large new dark spot or blank area in the center of your vision
- Sudden increase in floaters combined with vision loss
- A curtain or shadow spreading across your visual field
These symptoms may indicate a submacular hemorrhage or another serious retinal event. Time is critical. The sooner treatment begins, the better the chance of preserving vision.
If you have been diagnosed with any form of AMD, regular visits to a retina specialist are essential. Early detection of wet AMD conversion (when dry AMD progresses to wet AMD) and prompt treatment of new bleeding can make a significant difference. Your retina specialist will recommend a follow-up schedule based on the stage and activity of your condition.
Questions and Answers
Treatment should be sought as soon as possible, ideally within days of symptom onset. Blood under the macula begins damaging photoreceptors rapidly through clot contraction, iron toxicity, and nutrient blockage. Earlier intervention is generally associated with better visual outcomes. If you notice a sudden drop in vision, contact a retina specialist immediately or go to the nearest emergency room.
Visual recovery varies widely depending on the size and duration of the hemorrhage before treatment. Some patients regain meaningful central vision, while others experience lasting vision loss despite treatment. In the Submacular Surgery Trial, only 11 percent of untreated patients achieved visual acuity better than 20/200 at two years (Submacular Surgery Trials Research Group). Treatment significantly improves the odds of a better outcome, but results cannot be predicted with certainty.
Do not stop taking blood thinners without consulting the doctor who prescribed them. Blood thinners are prescribed for serious conditions such as heart disease, atrial fibrillation, and stroke prevention. While research shows that blood thinner use increases the risk of macular hemorrhage, the decision to modify these medications must be made collaboratively. Your retina specialist and prescribing physician should weigh the risks and benefits together.
Pneumatic displacement is a less invasive office-based procedure. A gas bubble is injected into the eye to push blood away from the center of the macula. Vitrectomy is a surgical procedure performed in an operating room. The vitreous gel is removed and clot-dissolving medication can be delivered directly beneath the retina. Both approaches have shown similar visual outcomes when combined with anti-VEGF therapy. Your retina specialist will recommend the most appropriate option based on the hemorrhage and your individual circumstances.
Recurrence is a meaningful concern. One study found a recurrence rate of 51.1 percent over an average follow-up of approximately 37 months in patients with wet AMD (Kim et al., PMC, 2015). Consistent anti-VEGF treatment and regular monitoring by a retina specialist are the most effective strategies for reducing this risk. Keeping all scheduled injection appointments and reporting any new visual symptoms promptly are essential steps in long-term management.