Haemorrhage at the macula causes deterioration of visual acuity within seconds or minutes. Biomicroscopy reveals a dome-shaped acute bleeding in the macular area, but the precise localisation of the blood—that is, subhyaloidal or macular—is mostly unknown. In this issue of the British Journal of Ophthalmology, De Maeyer et al (see page 869)¹ identify the sub-internal limiting membrane (ILM) cleavage plane as the site of haemorrhage in their patients, and present vitrectomy as an excellent treatment option for this pathology.

Different primary causes of subhyaloidal or macular haemorrhage have been stated, the most common being Valsalva retinopathy and Terson syndrome. In addition, such haemorrhages may occur secondary to vascular diseases such as arteriosclerosis, hypertension, retinal artery or vein occlusion, diabetic retinopathy, retinal macroaneurysm, chorioretinitis, blood disorders as well as shaken baby syndrome, age-related macular degeneration, and can also occur spontaneously or as a result of trauma.^2–9

In previous studies, the sharply demarcated, dome-shaped haemorrhage has been assumed to be in the subhyaloidal space, anterior to the ILM.^6,10,11 Although some authors identified a sub-ILM haemorrhage by glistening reflexes and surface striae,^12,13 others disputed the reliability of biomicroscopy in locating the plane of haemorrhage.^2,10,14–18 A definitive sub-ILM haemorrhage had been demonstrated in selected cases, where the cleavage plane could be identified by ophthalmoscopy, because of the presence of previously detached vitreous at the area of the sub-ILM haemorrhage,^{3,10,12,19–21} by echography,²² by optical coherence tomography (OCT) …