Vitrectomy with Subretinal Tissue Plasminogen Activator for Submacular Hemorrhage: A Multicenter Retrospective Analysis of Functional and Anatomical Outcomes Across Multiple Etiologies.

To evaluate visual and anatomical outcomes of pars plana vitrectomy (PPV) with subretinal tissue plasminogen activator (tPA) and gas or air tamponade for large submacular haemorrhage (SMH>4 disc diameters) of varied etiologies and assess postoperative anti-vascular endothelial growth factor (anti-VEGF) requirements in a multicenter real-world cohort. This retrospective, two-center study included 32 eyes undergoing PPV with subretinal tPA (25-50 µg/0.1-0.2 mL) and SF6 or air tamponade, followed for ≥6 months. The primary outcome was change in best-corrected visual acuity (BCVA). Secondary outcomes included central macular thickness (CMT), SMH dimensions, subretinal/intraretinal fluid (SRF/IRF) status, intraocular pressure (IOP), and anti-VEGF use. Mean patient age was 60.8 ± 19.1 years; etiologies included polypoidal choroidal vasculopathy (PCV; 53.1%), neovascular age-related macular degeneration (nAMD; 28.1%), trauma (12.5%), and retinal artery macroaneurysm (RAM; 6.3%). BCVA improved significantly from 1.13 ± 0.30 to 0.56 ± 0.26 logMAR (P<0.001), with 55.2% gaining ≥3 lines. CMT reduced from 501 ± 219 to 276 ± 70 µm (P<0.001), and SMH size decreased from 5 ± 2 to 0 disc diameters by 6 months. SRF resolved in 65.65% of eyes (P<0.001), while IRF remained stable (P=0.51). IOP normalized after a transient 1-month rise. Mean anti-VEGF use was 1.2 injections/eye (bevacizumab 88.2%, brolucizumab 11.8%). No major complications occurred; one transient vitreous hemorrhage and three cataract progressions were noted. PPV with subretinal tPA achieved rapid hemorrhage clearance, significant visual gain, and durable anatomical restoration with minimal complications and limited anti-VEGF need. It offers an effective, safe option for large SMH across etiologies, enabling timely foveal recovery and improved long-term functional outcomes.