AIM: To evaluate the efficacy of retinal laser photocoagulation and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) for hemorrhagic retinal arterial macroaneurysm (RAM). METHODS: This was a retrospective clinical study. Patients with hemorrhagic RAM were divided into 4 groups defined by different treatments: a retinal laser photocoagulation therapy monotherapy group, an anti-VEGF intravitreal injection monotherapy group, a laser and anti-VEGF combination therapy group, and an observation group. Visual acuity (VA), central macular thickness (CMT), and retinal hemorrhage area (RHA) were collected. RESULTS: Forty-seven eyes of 47 patients were enrolled. VA improved and had a significant difference between baseline and final in each treatment group (logMAR; laser group: 1.90±0.53 vs 1.05±0.63, P<0.001; anti-VEGF group: 1.75±0.63 vs 1.12±0.54, P=0.009; combination group: 1.76±0.38 vs 1.01±0.52, P<0.001); however, VA decreased and had no significant difference in observation group (1.63±0.51 vs 1.76±0.61, P=0.660). CMT decreased and had a significant difference between baseline and final in each group (laser group: 815.16±310.83 vs 252.05±83.90 μm, P<0.001; anti-VEGF group: 725.00±290.79 vs 203.56±69.89 μm, P=0.001; combination group: 595.50±186.51 vs 253.13±55.06 μm, P=0.001; observation group: 758.88±195.65 vs 267.00±120.90 μm, P=0.001). RHA were 28.99±28.15, 25.94±11.58, 19.64±8.97, and 27.45±13.76 mm2 in laser group, anti-VEGF group, combination group and observation group, respectively. RHA was statistically correlated with final VA (P=0.032) in the observation group. CONCLUSION: Both laser and anti-VEGF treatments are effective for hemorrhagic RAM. Combination therapy reduces the number of injections of anti-VEGF. RHA is a visual prognosis predictor in the natural history of hemorrhagic RAM.