Vitreous Haemorrhage

Bleeding into the vitreous cavity or the space between the vitreous and the retina. Incidence about 7 per 100,000 per year.

• Causes (most common first):
  • Proliferative diabetic retinopathy (about 35 to 50 percent): rupture of fragile neovascular fronds, often after posterior vitreous separation.
  • Posterior vitreous detachment with retinal tear (about 10 to 15 percent): bleeding from a torn vessel; any dense haemorrhage with sudden onset in a non-diabetic patient is a retinal tear until proven otherwise.
  • Proliferative retinopathy from retinal vein occlusion, sickle cell retinopathy, retinopathy of prematurity, and Eales disease.
  • Trauma (blunt and penetrating), ruptured retinal macroaneurysm, age-related macular degeneration with polyps or neovascular membranes, choroidal melanoma, vitreous haemorrhage in Terson syndrome (after subarachnoid haemorrhage or severe head injury), shaken baby syndrome, avulsion of a retinal vessel, and blood disorders or anticoagulants.
• Complications: proliferative vitreoretinopathy, tractional detachment, ghost cell glaucoma, haemosiderosis, and amblyopia (children).

• Sudden painless loss of vision or a shower of floaters, "cobwebs", or a red haze; vision ranges from near normal to light perception, worse on waking if blood has settled (inferior haemorrhage) and clearer after sitting upright.
• Photopsia suggests a retinal tear; sudden unilateral visual loss in a diabetic suggests neovascular bleeding.
• Examination: reduced or absent red reflex, blood in the vitreous (fresh haemorrhage red, older ochre-yellow), view of the fundus obscured, relative afferent pupillary defect only if retinal detachment is extensive, and pigment cells in the anterior chamber.
• Premacular (subhyaloid) haemorrhage with a boat-shaped fluid level; in infants, Terson syndrome and non-accidental injury are important causes.

• Visual acuity, pupils, intraocular pressure, slit lamp, and dilated fundus examination, with scleral depression to look for tears even when view is partial; examine the fellow eye for diabetic or other retinopathy, and signs of neovascularisation.
• B-scan ultrasound whenever the view is obscured: excludes retinal detachment, retinal tear, and tumour; repeat every 1 to 2 weeks until the fundus can be seen.
• Optical coherence tomography and fluorescein angiography as soon as the view allows.
• Systemic work-up: blood pressure, glucose, glycated haemoglobin, full count and clotting; sickle test in appropriate patients; imaging of the head if Terson syndrome or non-accidental trauma is suspected.

• Initial: upright positioning or head elevation at 30 to 45 degrees (also at night) to allow blood to settle inferiorly and give a view of the superior retina; avoid strenuous activity and straining; review aspirin or anticoagulants but do not stop essential drugs without medical advice.
• Observation: most non-diabetic haemorrhages without a tear or detachment clear in 4 to 12 weeks (about 1 percent per day); repeat ultrasound if the view is poor.
• Retinal tear: laser retinopexy or cryopexy as soon as seen, because of the risk of detachment.
• Proliferative diabetic retinopathy: intravitreal anti-VEGF (bevacizumab 1.25 mg or aflibercept 2 mg), panretinal photocoagulation (1200 to 2000 spots) as soon as the view allows; systemic control of glucose, blood pressure and lipids.
• Pars plana vitrectomy (23, 25 or 27 gauge) with removal of blood, treatment of the bleeding source, and endolaser panretinal photocoagulation. Indications:
  • Non-clearing haemorrhage after 1 to 3 months (earlier for type 1 diabetes or when the fellow eye is poor).
  • Retinal detachment (tractional or rhegmatogenous), or retinal tear with dense haemorrhage preventing treatment.
  • Rubeosis iridis or neovascular glaucoma with obscured view.
  • Massive subhyaloid and premacular haemorrhage in children and in the visual axis (Nd:YAG laser hyaloidotomy for premacular haemorrhage in selected patients).
  • Dense haemorrhage in infants to prevent amblyopia.
• Postoperative care: topical steroid and antibiotic, intraocular pressure monitoring, treat recurrent haemorrhage with gas exchange or washout.
• Counselling: warning signs of retinal detachment, systemic control, and follow-up.