VITREOUS HEMORRHAGE

Vitreous hemorrhage is a significant cause of sudden vision loss. Vitreous hemorrhage can be due to a wide variety of causes including proliferative diabetic retinopathy, posterior vitreous detachment (PVD) with or without retinal tear or retinal detachment, and other retinal vascular, hereditary, and inflammatory diseases.

Symptoms

Most patients experience an acute loss of vision. It is not unusual for the hemorrhage to occur at night and the visual loss is first noticed by the patient on waking. Some patients, particularly patients with diabetes,

report seeing a distinct red stream as the bleeding occurs. Associated symptoms of flashing lights may indicate an underlying PVD or retinal tear.

Clinical Features

On slit lamp examination, red blood cells may be seen on the posterior lens surface and in the anterior vitreous directly behind the lens. Blood may be present in the vitreous cavity (intravitreal hemorrhage) or behind the vitreous (subhyaloid hemorrhage). If the vitreous hemorrhage does not resolve within a few weeks, the blood will lose its hemoglobin and will become gray or white in color. Occasionally, red blood cells migrate into the anterior chamber, and these cells may obstruct the trabecular meshwork, causing a rise in intraocular pressure.

Vitreous hemorrhage is often accompanied by other retinal findings including posterior vitreous detachment, retinal tear or detachment, vein occlusion, proliferative diabetic retinopathy, trauma, macroaneurysm, or macular degeneration.

Ancillary Testing

Ultrasound examination is invaluable in the assessment of eyes with significant vitreous hemorrhage. Detection of a posterior vitreous detachment, submacular hemorrhage, and even large retinal tears is possible with B-scan echography. Serial ultrasound examinations

are required to follow up patients in the absence of an adequate view of the retina.

Pathology/Pathogenesis

A PVD with or without a retinal tear or retinal detachment can cause vitreous hemorrhage by exerting traction on a retinal blood vessel. Abnormal retinal vessels in diabetic retinopathy, retinal vein occlusions, or other proliferative retinopathies can bleed because of vitreous traction on the preretinal blood vessels. Other causes

of vitreous hemorrhage include choroidal neovascularization with “breakthrough bleeding,” X-linked juvenile retinoschisis, and subarachnoid hemorrhage (Terson’s syndrome).

Treatment/Prognosis

Vitreous hemorrhage will generally clear spontaneously, and vision will return as long as the underlying cause is treated. Nonclearing vitreous hemorrhage may be treated with elective pars plana vitrectomy, although urgent intervention is required in the presence of retinal detachment.

System Evaluation

Vitreous hemorrhage is often associated with diabetes and hypertension; these conditions should be tested for in the absence of a definite underlying cause.

Proliferative diabetic retinopathy is a common cause of vitreous hemorrhage. The vitreous provides a scaffold for the proliferation of the new vessels. Contraction of the vitreous may lead to vitreous hemorrhage or traction retinal detachment.

Posterior vitreous detachment (PVD) may be associated with vitreous even in the absence of retinal tear or detachment. This patient with an acute PVD has a vitreous hemorrhage extending from a retinal vessel.

In patients with regressed neovascularization following laser photocoagulation, posterior vitreous detachment may lead to vitreous hemorrhage.

The presence of a vitreous hemorrhage in the setting of acute posterior vitreous detachment raises the suspicion of a retinal tear or detachment.

Breakthrough vitreous bleeding may occur in patients with exudative age-related macular degeneration and massive subretinal hemorrhage.

Fundus photograph of a patient with chronic vitreous hemorrhage related to proliferative diabetic retinopathy. Note the yellow coloration of the vitreous hemorrhage due to changed hemoglobin.

SELECTED REFERENCES

Amyloidosis

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Asteroid Hyalosis

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Idiopathic Vitritis

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Persistent Hyperplastic Primary Vitreous

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Posterior Vitreous Detachment

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Proliferative Vitreoretinopathy

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Vitreous Hemorrhage

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