Vitreous Hemorrhage

Aka: Vitreous Hemorrhage

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II. Definitions

  1. Vitreous Hemorrhage
    1. Blood extravasates into the vitreous cavity

III. Epidemiology

  1. Incidence: 7 per 100,00 per year in U.S.

IV. Pathophysiology

  1. Most commonly caused by Diabetic Retinopathy, Eye Trauma or Posterior Vitreous Detachment
  2. Even a small amount of blood (12.5 uL) in the 5 ml vitreous cavity can result in near complete opacification of Vision
  3. Vision Loss may take months to improve, with only 1% cleared per day
    1. Clotted blood may remain suspended in the vitreous, before it settles to the floor of the chamber and is resorbed
  4. Mechanisms
    1. Normal Retinal blood vessel rupture
      1. Eye Trauma (44% of cases in age <40 years old, second most common cause overall)
      2. Posterior Vitreous Detachment
      3. Shaken Baby Syndrome
    2. Pathologic structure bleeding
      1. Neovascularized Retina in proliferative Diabetic Retinopathy (35% of all cases)
      2. Central Retinal Vein Occlusion (CRVO)
    3. Hemorrhage extension from other sources via the Retina
      1. Microaneurysms
      2. Tumors

V. Risk Factors

  1. Diabetes Mellitus (Diabetic Retinopathy)
  2. Coagulopathy
  3. Retinal Tear (from Posterior Vitreous Detachment)
  4. Proliferative sickle Retinopathy (Sickle Cell Anemia)
  5. Eye Trauma
  6. Macular Degeneration
  7. Retinal artery micro-aneurysm
  8. Shaken Baby Syndrome
  9. Central Retinal Vein Occlusion (CRVO)
  10. Terson Syndrome (associated with Subarachnoid Hemorrhage)
    1. Occurs in 20-30% of SAH cases, and is associated with a worse prognosis
  11. Coagulopathy
    1. Thrombocytopenia
    2. Idiopathic Thrombocytopenic Purpura
    3. Hemophilia
    4. Leukemia

VI. Symptoms

  1. Painless, unilateral Acute Vision Loss lasting for minutes to hours
    1. Visual Floaters, "cobwebs" or cloudy Vision
    2. Red visual hue
    3. Often worse in the morning after the blood has settled over the Macula

VII. Signs

  1. Funduscopy
    1. Red Haze of Fundoscopy obscures the Retina
  2. Pupil reflex
    1. Normal (consider Retinal Detachment if abnormal pupil reflex)
  3. Slit Lamp
    1. Evaluate for Red Blood Cells in anterior chamber

VIII. Imaging

  1. Ocular Ultrasound
    1. Excludes alternative diagnosis (e.g. Retinal Detachment)
    2. Vitreous Hemorrhages (location and size)
      1. Collections of irregular hyperechoic (white) blood suspended in anechoic (black) chamber
      2. Hemorrhages may swirl (as in a washing machine) with Extraocular Movement

IX. Management

  1. Urgent ophthalmology Consultation evaluation (best within 24 hours)
  2. General, conservative measures
    1. Bedrest
    2. Elevate head of bed to 30 degrees
    3. Hold Anticoagulants if possible (including Aspirin and NSAIDs)
    4. Avoid strenuous activity (that might increase Blood Pressure and worsen spontaneous bleeding)
  3. Ophthalmology procedures
    1. Pars Plana Vitrectomy to remove blood collections from vitreous
      1. Timing of procedure is variable depending on cause
      2. In some cases, emergent vitrectomy is considered
      3. In Diabetic Retinopathy, vitrectomy is considered after the first month and may delayed up to 12 months
    2. Panretinal photocoagulation
      1. Indicated for proliferative Diabetic Retinopathy (to reduce recurrent bleeding risk)

X. Prognosis

  1. Better prognosis if risk of recurrent bleeding is low (Vision improvement in >77% of cases)
    1. Isolated Posterior Vitreous Detachment
    2. Retinal Detachment
  2. Poor prognosis when higher risk for recurrent bleeding
    1. Proliferative Diabetic Retinopathy (if not treated with photocoagulation)

XI. References

  1. Hartmann (2016) Crit Dec Emerg Med 30(6): 3-11
  2. Yu and Jasani (2024) Crit Dec Emerg Med 38(1): 27-34

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