Sub-Internal Limiting Membrane Foveal Hemorrhage Under Tension: OCT Biomarkers Predicting Macular Hole Formation after Submacular Hemorrhage.

Purpose: To identify preoperative clinical characteristics of macular hole (MH) formation after vitrectomy for submacular hemorrhage (SMH) due to ruptured retinal arterial macroaneurysm (RAM).

Methods: We retrospectively analyzed eyes with SMH due to ruptured RAM in patients who underwent vitrectomy and had more than one month of follow-up. We compared background factors and imaging findings between groups classified by MH presence. The primary outcomes were best-corrected visual acuity, and fundus and optical coherence tomography findings.

Results: We identified 48 eyes with SMH due to RAM rupture. MHs were identified in 8 eyes (16.3%); 4 intraoperatively and 4 postoperatively. Preoperative OCT findings revealed that all MH cases exhibited the highest retinal thickness at the foveal lesion with sub-internal limiting membrane (ILM) hemorrhage preoperatively. We termed this finding the "foveal mountain peak" (FMP) sign, characterized by sub-ILM hemorrhage where the peak of the retinal thickness coincides with the fovea. The incidence of FMP sign (+) cases was significantly higher in the MH (+) group compared with the MH (-) group (100% vs. 47.5%, respectively; P = 0.006).

Conclusion: The presence of the FMP sign may indicate an increased risk of SMH-associated MH.