Patients with thick submacular hemorrhage complicating age-related macular degeneration and other disorders typically have a poor visual prognosis. A new outpatient procedure, consisting of intravitreal injection of tissue plasminogen activator and gas followed by brief prone positioning, is effective in displacing thick submacular blood and facilitating visual improvement in most patients. Injection of gas alone also appears to be effective in many eyes. The procedure is technically simple and the rate of serious complications appears to be acceptably low. Although the final visual outcome is often limited by progression of age-related macular degeneration, significant and stable visual recovery is possible in selected eyes. Prospective clinical trials are needed to clarify the role for intravitreal tissue plasminogen activator and to provide definitive outcome comparisons with other management approaches.