Title: Vitreous Hemorrhage
Authors: Trey Winter, 1st Year Medical Student, University of Utah; Samuel Whittier, 4th Year Medical Student, University of Utah
Photographer: James Gilman, CRA, FOPS
CORE Location: Basic Ophthlamology Review > II. Anatomical Approach to Eye Disease > Vitreous > 2. Vitreous Hemorrhage
Definition: Vitreous hemorrhage is the extravasation of blood from vessels into the vitreous humor. The vitreous is 99% water, with the remaining 1% comprised of collagen and hyaluronic acid. Healthy vitreous has a gelatinous consistency with a clear appearance for optimal optic clarity. When bleeding into the vitreous occurs, painless vision loss may result. Vitreous hemorrhage is most frequently caused by diabetic retinopathy (most common in adults), posterior vitreous detachment (PVD), trauma (most common in children), and other vascular or ocular conditions.
Presentation: Vitreous hemorrhage typically presents with a painless reduction in vision, floaters, spider-web apparitions, and potentially red tinted vision. On examination, vitreous hemorrhage can obstruct light from focusing on the retina causing decreased vision as well as blocking the examiner’s view, resulting in a darkened or diminished red reflex. The extent of these symptoms is directly proportional to the amount of blood in the vitreous. Some patients may report photophobia as an accompanying sign of vitreous hemorrhage. Visual symptoms may be worse first thing in the morning as blood can settle on the macula while laying flat.
Complications: Just as with the presentation of vitreous hemorrhage, most complications associated with this condition relate to the amount of blood and length of time the blood remains in the vitreous. Vitreous hemorrhage spontaneously clears less quickly in younger eyes with a well-formed vitreous.
- Hemosiderosis bulbi – Hemoglobin/hemosiderin depositing on structures in the eye
- Proliferative vitreoretinopathy – Occurs when fluid from the vitreous humor enters a retinal hole
- Hemolytic glaucoma – RBCs and macrophages that have engulfed RBCs obstruct outflow in the trabecular meshwork, causing an elevation in intraocular pressure
- Ghost cell glaucoma – RBC shells devoid of their hemoglobin become less pliable and can also obstruct the angle, but the presentation is typically more delayed.
- Retinal tear/detachment – Occurs as the partially attached vitreous pulls on the retina
Differential Diagnosis: The differential for vitreous hemorrhage includes various vascular conditions and trauma.
Vascular conditions on the differential diagnosis include but are not limited to:
- Proliferative diabetic retinopathy
- Retinal vein occlusion
- Retinal tear/detachment
- Hypertensive retinopathy
- Sickle Cell retinopathy
- Other Retinopathies
Other conditions on the differential include:
- Globe injury
- Shaken baby syndrome
- Various blood disorders/coagulopathies
- Age-related macular degeneration
Diagnosis: Vitreous hemorrhage can be caused by several different conditions, the most common being diabetic retinopathy, PVD, and trauma. Diagnosis is made from a history and physical examination. A history detailing a sudden loss of vision, reddened vision, or floaters as defined above are indicative of vitreous hemorrhage. Patients with a history of trauma, an ocular surgery, or diabetes are also at risk for vitreous hemorrhage. Patients taking clopidogrel or warfarin have a small increased risk of vitreous hemorrhage during PVD.
A physical examination for vitreous hemorrhage should include a careful slit lamp exam and dilated exam to view the posterior structures of the eye (retina, optic nerve). A slit lap exam may show red blood cells anterior or posterior to the lens.
Ophthalmoscopy will allow the practitioner to directly visualize the hemorrhage within the vitreous cavity. However, the view may be partially or completely obscured by the hemorrhage, in which case an ultrasound or B-scan should be performed to assess the integrity of the posterior anatomy of the eye.
B-scan ultrasonography shows more localized vitreal hemorrhage (left), and more diffuse hemorrhage with areas of clumping throughout vitreous (right).
Management/Treatment: The key to management and treatment of vitreous hemorrhage is to identify and treat the underlying cause. This is most easily accomplished with direct visualization of the retina. If the view of the retina is blocked, examining the other eye can provide valuable clues, especially if the underlying etiology is related to a bilateral process such as diabetic retinopathy. Additionally, in the absence of a clear view of the retina, B-scan ultrasonography is indicated to evaluate for a detached retina. If the retina is detached the patient needs urgent evaluation (ideally within 24 hours) by a retina specialist.
The patient should be advised to reduce strenuous activity while new clots are forming, as well as sleep at an angle to allow the blood to settle toward the bottom of the eye. If neovascularization is the cause, laser pan-retinal-photocoagulation or intravitreal anti-VEGF injections potentially combined with vitrectomy may be indicated to reduce the risk of ongoing bleeding and abnormal vessel growth. Non-clearing vitreous hemorrhages, ghost cell glaucoma, and glaucoma may also necessitate a vitrectomy. Once retinal detachment has been ruled out, follow-up can be done on an outpatient basis.
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Faculty Approval: Griffin Jardine, MD