Vitreous hemorrhage

Background

• Bleeding into the vitreous humor of the eye
  • Vitreous is avascular substance that helps keep retina in place
  • Traction at its attachments at the ora serrata and optic disc can result in bleeding
  • Neovascularization (associated with DM) can result in weak vessels with high propensity for bleeding
• May cause permanent blindness

Causes

• Diabetic retinopathy
• Trauma
  • Shaken baby syndrome
• Sickle cell disease
• Posterior vitreous detachment
  • Elderly
• Retinal tear
• Terson Syndrome (Association with Subarachnoid Hemorrhage (SAH))

Clinical Features

• Sudden, painless vision loss
• Acute Onset Flashers and Floaters
• Generalized unilateral hazy vision

Differential Diagnosis

Acute Vision Loss (Noninflamed)

• Painful
  • Arteritic anterior ischemic optic neuropathy
  • Optic neuritis
  • Temporal arteritis^†
• Painless
  • Amaurosis fugax
  • Central retinal artery occlusion (CRAO)^†
  • Central retinal vein occlusion (CRVO)^†
  • High altitude retinopathy
  • Open-angle glaucoma
  • Posterior reversible encephalopathy syndrome (PRES)
  • Retinal detachment^†
  • Stroke^†
  • Vitreous hemorrhage
  • Traumatic optic neuropathy (although may have pain from the trauma)

^†Emergent Diagnosis

Evaluation

Vitreous Hemorrhage on ultrasound

In the setting of trauma, must assess for Globe Rupture

• Visual acuity
  • Degree of vision loss proportional to size of hemorrhage
• Assess for coagulopathy
  • INR for patients on warfarin
• Fundoscopy
  • May show gross hemorrhage
  • Blood may obscure retina
  • Decreased red reflex
• Ultrasound
  • Bright echoes in posterior chamber
  • Moving the eye can cause swirling of hemorrhage known as "washing machine sign"
  • Small dots or mobile lines may represent early, mild hemorrhage
  • Look for retinal injury/tears
    • require operative intervention

Management

1. Correct coagulopathy
2. Ophtho consult (should see ophtho within 24-48 hours)
   • Treatment directed at underlying cause
3. Avoid NSAIDs and anticoagulants
4. Elevate the head of the bed
5. Treat nausea/vomiting

See Also

• Acute vision loss (noninflamed)
• Ocular ultrasound