Overview
Vitreous haemorrhage is bleeding into the vitreous humour (found between the lens and the retina) and is a cause of sudden and painless vision loss. It can affect vision ranging from floaters to complete visual loss.
Vitreous haemorrhage is an important differential for sudden visual loss in people with diabetes mellitus.
Epidemiology
- Proliferative diabetic retinopathy is the most common underlying cause
- In children and young adults, ocular trauma is the most common cause
- In infants, shaken baby syndrome can cause vitreous haemorrhage – suspect if bilateral
Causes
90% of cases are due to:
- Proliferative diabetic retinopathy
- Posterior vitreous detachment
- Ocular trauma
Other causes may be:
- Atherosclerosis
- Hypertension
- Retinal vein occlusion and subsequent neovascularisation
- Wet age-related macular degeneration
- Ocular tumours
Risk Factors
- Diabetes mellitus
- Trauma
- Sickle cell disease
- Ocular trauma
- Coagulopathies
- Anticoagulant use
Presentation
Patients usually have an acute and painless loss of vision. Some other features are:
- Sudden onset of floaters preceding the vision loss
- A red hue in the vision – due to blood blocking the light trying to reach the retina
- Decreased visual acuity depending on where the haemorrhage is and how much haemorrhaging there is
Differential Diagnoses
Central retinal vein occlusion (CRVO)
- CRVO can lead to vitreous haemorrhage
- Haemorrhages may be seen on fundoscopy which may make it difficult to distinguish
- Haemorrhages are usually more severe
Posterior vitreous detachment
- Sudden onset of flashing lights in the peripheries of vision
- Sudden onsets of floaters may be seen
- Fundoscopy shows a Weiss ring
Retinal detachment
- May have flashes and floaters
- Vision loss may be described as a curtain or veil coming down
Investigations
All patients must have both eyes examined:
- Fundoscopy:
- May show blood and haemorrhages in the vitreous cavity
- Slit-lamp examination:
- Shows blood in the anterior vitreous
- Gonioscopy:
- To look for neovascularisation and assess the angle
- Fluorescein angiography:
- To look for neovascularisation
- CT of the orbit:
- If there is an open globe injury
Management
- Most patients are observed and conservatively managed. They also have their risk factors modified where possible.
- If neovascularisation is seen: laser photocoagulation
Patient Advice
- Patients should avoid strenuous activity as increased blood pressure may disrupt clots and start new bleeds
- Patients should keep their head elevated when sleeping to improve blood settling
- Patients should continue taking their anticoagulation, they do not worsen vitreous haemorrhages
Complications
- Neovascularisation
- Raised intraocular pressure and glaucoma
Prognosis
- The prognosis is worse with patients who are diabetic or have age-related macular degeneration
- The blood clears at around 1% per day
