Vitreous hemorrhage – classification

Description

The normal eye contains approximately 4mL of vitreous, of which 99% is water. Since the healthy vitreous is avascular, hemorrhage usually arises from blood vessels associated with the retina or other intraocular tissues. In young patients the hyaloid membrane containing the vitreous is more likely to be intact and attached to the retina, and a retrohyaloid (subhyaloid, pre-retinal or retrovitreous) hemorrhage may result. With age, intravitreous hemorrhage is more likely, as the vitreous becomes more liquefied (synchysis senilis), shrinks (vitreous syneresis) and posterior vitreous detachment (PVD) is more prevalent.

Etiology

Common causes of vitreous hemorrhage include:

(a) Bleeding from abnormal new retinal vessels, most often secondary to ischemia

(b) Tearing of normal retinal blood vessels, most often due to vitreous traction or trauma

(c) Breakthrough bleeding from choroidal neovascularization or tumor

(d) Developmental or idiopathic conditions.

Examples for these common causes are listed in the Table:

Table:Common causes of vitreous hemorrhage and examples
Category	Examples
Proliferative retinopathy	Diabetes, Sickle cell disease causing retinal ischemia
Vascular occlusion	Branch or central retinal vein occlusion, leading to ischemic retinopathy, retinal macroaneurysm
Choroidal neovascularization	Wet age-related maculopathy
Trauma	Blunt or penetrating trauma, Intraocular foreign body, Subarachnoid or subdural hemorrhage (Terson’s syndrome), Valsalva retinopathy
Intraocular tumor	Malignant melanoma, Lymphoma
Pediatric	Birth trauma, Shaken baby syndrome, Retinopathy of prematurity
Developmental	Coats’ Disease (Retinal Telangiectasia), Von Hippel Lindau syndrome, Retinoschisis – Juvenile X-linked
Idiopathic	Eales disease, Sarcoidosis, Intermediate uveitis/pars planitis

Symptoms

Mild hemorrhage: Recent onset of multiple floaters and flashing lights (photopsia)

Moderate hemorrhage: possible “red vision” (erythopsia) or “smoke signals” (visual haze).

Severe hemorrhage: Sudden painless loss of vision

Signs

If the posterior hyaloid face is intact then a pre-retinal hemorrhage is more likely, with a dense well-circumscribed “boat shape” appearance. The bright red blood will shift readily with eye movements or head tilt.

A hemorrhage within the vitreous usually has no definite borders. It may partly or completely obscure the retina, optic nerve and blood vessels. In a severe vitreous hemorrhage there may be no fundus red reflex. As the vitreous hemorrhage breaks down, its color changes to orange and yellow.

Underlying retinal or other pathology may be evident at the posterior pole or in the retinal periphery. Neovascularization of the iris or angle may be evident on gonioscopy.  Intraocular pressure may be raised if secondary glaucoma has developed.

Potential complications of persistent vitreous hemorrhage include:

(a) hemosiderosis bulbi, where retinal toxicity to iron ions may occur subsequent to hemoglobin breakdown.

(b) secondary glaucoma from blockage of the trabecular meshwork. The secondary glaucoma may relate to ghost cells in the vitreous, hemolysis or hemosiderosis.

(c) visual compromise in infants e.g. amblyopia

(d) increased risk of retinal tears or detachment

Prevalence

Rare (approximately 1/10,000)

Significance

Sight threatening requiring prompt investigation and possible treatment

Diff. Diagnosis

Vitritis, retinal detachment

See Also

See listing in Table

Management

Additional Investigations 

The underlying cause should be promptly identified (see Etiology above). Ultrasound if vitreous hemorrhage is severe, to assess retina for breaks, detachment, tumor etc. Fluoroscein angiography may assist in identifying the source of the bleed.

Oral medication

Discontinue aspirin and other anti-clotting agents if possible

Review

VH may clear spontaneously and depending upon the underlying cause, conservative management with review may be all that is required

Laser surgery

Laser photocoagulation may be indicated to close a retinal break, seal a leaking vessel, or to treat proliferative retinopathy.

Incisional Surgery

Pars plana vitrectomy allows surgical removal of non-clearing blood. Indications may include recurrent or chronic vitreous hemorrhage, or the presence of associated conditions such as proliferative diabetic retinopathy retinal detachment, rubeosis or other secondary glaucoma. Retinal detachment or melanoma are likely to require surgical management.

Advice

Bed rest may be indicated, with the head elevated, to allow blood to settle inferiorly. To avoid a rebleed, the patient should avoid a valsalva maneuver; any activity causing a sudden increase in intrathoracic pressure, such as straining or physical activity.

Table 1

Common causes of vitreous hemorrhage and examples