Vitreous haemorrhage

Question 1

Define vitreous haemorrhage.

Answer 1

Bleeding into the vitreous humour

Question 2

How common is vitreous haemorrhage?

Answer 2

One of the most common causes of sudden painless loss of vision
Spontaneous vitreous haemorrhage has an incidence of around 7 cases per 100000 patient-years

Question 3

What are the risk factors for vitreous haemorrhage?

Answer 3

• Proliferative diabetic retinopathy (>50%)
• Posterior vitreous detachment
• Ocular trauma - most common cause in children and young adults

Question 4

What are the signs and symptoms of vitreous haemorrhage?

Answer 4

Subacute onset of:

• painless visual loss or haze (commonest)
• red hue in the vision
• floaters or shadows/dark spots in the vision

O/E:

• decreased visual acuity - depends on location, size and degree of vitreous haemorrhage
• visual field defect - if severe haemorrhage

Question 5

How do you diagnose vitreous haemorrhage?

Answer 5

Dilated fundoscopy - may see the bleed in vitreous cavity
Slit-lamp examination - red blood cells in anterior vitreous
USS - rules out retinal tear/detachment and if haemorrhage obscures the retina
Fluorescein angiography - identifies neovascularisation
Orbital CT - used in open globe injury

Retinal detachment must be excluded

Question 6

What are the mechanisms of vitreous haemorrhage?

Answer 6

1. retinal vessels that are vulnerable to bleeding - e.g. neovascularisation and VEGF stimulation forms fragile vessels
2. rupture of normal retinal vessels due to stress - e.g. direct trauma, posterior vitreous detachment or retinal detachment
3. extension of blood from an adjoining source - e.g. microaneuryssm of retina or tumours

Question 7

What is the management of vitreous haemorrhage?

Answer 7

Immediate referral to eye emergency department
Exclude retinal detachment - USS
If retina attached: Observation +/- follow up - clearing of vitreous haemorrhage should be monitored and if recurs then refer for vitrectomy
If retina detached: urgent vitrectomy
DO NOT stop anticoagulation as it will not worsen the condition

NB: Retinal breaks are treated with cryotherapy or laser photocoagulation.

Question 8

What is a vitrectomy?

Answer 8

Removal of vitreous and any associated haemorrhage -> often causes involution of new vessels because it removes the platform on which these vessels grey

Question 9

What are the differentials for presence of floaters?

Answer 9

• Part of naural ageing process
• Posterior vitreous detachment - a common condition that occurs in about three-quarters of people over 65 years of age
• Retinal tears - in about half of people vitreous humour has separated from retina by age 50yrs which is usually non-problematic but need to be treated
• Retinal detachment
• Following eye surgery
• Infection
• Inflammation (uveitis)
• Eye injury

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