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Vitreous Hemorrhage

URGENT — Retina

Symptoms

  • sudden, painless vision loss: ranging from a mild "haze" to total darkness
  • floaters: black spots, "cobwebs," or "streaks" that move with the eye
  • photopsias: flashes of light, especially if the hemorrhage is caused by a retinal tear

Clinical Findings

Clinical presentation

  • diminished red reflex: the "orange glow" of the eye is dull or absent when viewed with an ophthalmoscope
  • obscured fundus: the doctor cannot see the retina clearly through the pool of blood
  • ochre membrane: in chronic cases, the blood turns a pale yellow-tan color as it breaks down

Associated signs

  • rbc in anterior chamber: red blood cells may "spill over" into the front of the eye
  • rapd: a mild pupillary defect may be present if the hemorrhage is extremely dense

Etiology

Proliferative (leaky vessels)

  • diabetic retinopathy: the most common cause; fragile new vessels (neovascularization) bleed easily
  • vein occlusion (brvo/crvo): back-pressure in the veins leads to bleeding
  • wet amd: advanced bleeding from under the retina can break through into the vitreous

Structural (mechanical tears)

  • pvd: the vitreous gel pulling away from the retina can tear a blood vessel
  • retinal tear/detachment: a full-thickness rip in the retina often causes immediate bleeding

Other

  • trauma: direct blunt or penetrating injury
  • terson syndrome: bleeding in the eye caused by a sudden brain hemorrhage (subarachnoid)

Red Flags

  • "no view": if the doctor cannot see the retina, a B-scan ultrasound is MANDATORY to rule out a hidden retinal detachment
  • flashes & floaters: suggests a retinal tear is the primary cause of the bleed
  • trauma: always exclude a "globe rupture" (a hole in the eye wall) if the injury was severe
  • monocular patient: if this is the patient's only seeing eye, surgical intervention (vitrectomy) is usually expedited

Investigations

Imaging

  • b-scan ultrasound: the single most important test when the retina is hidden; it "sees through" the blood using sound waves
  • ivfa: used once the blood clears slightly to find the "leaky" source

Clinical exam

  • slit lamp exam: check for "nvi" (new vessels on the iris) which suggests advanced diabetes or ischemia
  • check the other eye: the "healthy" eye often holds clues to the underlying cause (e.g., diabetic changes)

Treatment

Conservative management

  • observation: small bleeds often clear on their own over weeks to months
  • activity restriction: no strenuous exercise or blood-thinning meds (unless medically necessary)

Interventional

  • laser photocoagulation: to seal retinal tears or "zap" leaky diabetic vessels once they become visible
  • anti-vegf injections: to shrink abnormal new vessels in diabetes or AMD

Surgical

  • vitrectomy: surgery to physically remove the bloody gel; indicated for non-clearing bleeds (>2 months) or if a retinal detachment is found

Clinical Pearl

The most important question in vitreous hemorrhage: is there a retinal detachment hiding behind the blood? B-scan ultrasound is mandatory when the fundus is not visible. Never delay if detachment is suspected.

Differential Diagnosis

  • • vitritis (white blood cells from inflammation/infection; usually slower onset and painful)
  • • retinal detachment (can occur without bleeding, but often co-exists)
  • • asteroid hyalosis (calcium "sparkles" in the vitreous; looks like a snowstorm but vision is usually good)

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