Vitreous hemorrhage :Basics

Dr Pooja ChoudharyIII yr JR(M.S. Opht0)

MDM Hospital

Vitreous hemorrhage is the extravasation or leakage of blood into the areas in and around the vitreous humor of the eye.

In nondispersed hemorrhage: a view to the retina may be possible the location and source may be

determined.

Vitreous hemorrhage in the subhyaloid space is known as preretinal hemorrhage.

boat-shaped trapped in the potential space between the

posterior hyaloid and ILM settles out like a hyphema

Dispersed vitreous hemorrhage into the body of vitreous has no defined border and can range from a few small distinct red blood cells to total obscuration of the posterior pole

Mechanisms of Vitreous Hemorrhage1.Abnormal VesselsDiabetic retinopathy (31–54 percent of vitreous

hemorrhages are caused by diabetes)Neovascularization from branch or central retinal vein

occlusion (4–16 percent)Sickle cell retinopathy (0.2–6 percent)Eales disease

Sickle cell retinopathy

CRVO Eales disease

NPDR

PDR

2.Rupture of Normal VesselsRetinal tear (11–44 percent)Trauma (12–19 percent)Posterior vitreous detachment with retinal

vascular tear (4–12 percent)Retinal detachment (7–10 percent)Terson’s syndrome (0.5–1 percent)

3.Blood From Adjacent SourceMacroaneurysm (0.6–7 percent)Age-related macular degeneration (0.6–4

percent)

Wet ARMD

Others causes you must look :1.Ruptured arterial macroaneurysm .2. coat’s disease.3.ROP4.retinal capillary angioms of Von Hippel

Lindau syndrome.5.Congenital prepapillary vascular loop6.Retinal cavernous hemangiomas

Diagnosis can be made by correlating with age of pts: Infancy and child: birth trauma shaken baby syndrome child abuse, cogenital X-linked retinoschisis ROP Middle age : Eales disease trauma PVD Old age: exudative ARMD diabeties, BRVO PVD

Fundus of patient : child abuse

Symptoms:

Painless visual loss floaters cobwebs, shadows or a red hue. visual field defect /scotomas photopsia

Signs:

Red fundus reflex may be absent. No view to the fundus Red blood cell may be seen in anterior vitreous Chronic VH has a yellow ochre appearance from

Hb breakdown

Workup1. History: Patients should be questioned regarding a

history of trauma, ocular surgery, diabetes, sickle cell anaemia, leukaemia, carotid artery disease high myopia. Proper history taking most of the time save

time and make appropriate diagnosis.

2. Complete examination : a) Slit lamp examination with undilated pupil to check for iris neovascularisation b) Indirect ophthalmoscopy with scleral depression (avoid until 2 weeks after traumatic hyphaema/microhyphema)

c) Gonioscopy to evaluate neovascularisation of the angle d) IOP measurement. e) B-scan ultrasonography if complete view of the

posterior pole is obscured by blood. h)Fluroscein angiography may aid in defining the

etiology . Additionally it may be useful to highlight abnormalities in the contra lateral eye

Dilated examination of the contra lateral eye can help

provide clues to the etiology of the vitreous hemorrhage, such as proliferative diabetic retinopathy.

B-scan : is of great importance 1.To rule out any tumour /mass2.To rule out retinal detachment on if there is R.D indication of early surgery.3.To differentiate PVD from RD

B-Scan showing vitreous haemorrhage with PVD

Treatment directed at the underlying cause, if knownunreliable/noncompliant patients with

vitreous hemorrhage complicated with severe hyphema, patients may be admitted to the hospital for close observation.

most patients are monitored closely on OPD basis

.

1.Bed rest with the head of the bed elevated 30-45° with occasional bilateral patching to allow the blood to settle inferiorly, allowing a view of the superior peripheral fundus

2.Avoid drugs such as aspirin and other anticlotting agents when necessary.

The goal is to treat the underlying cause as quickly as possible.

1.Retinal breaks are closed by laser photocoagulation or cryotherapy (unlike cryotherapy, laser photocoagulation can close the compromised vessel in addition to the retinal tear);

2.RD are reattached with surgery3.Proliferative retinal vascular diseases are

treated with laser photocoagulation or cryotherapy (when there is no view of the retina).

Indications for surgical removal of the vitreous blood by pars plana vitrectomy include the following:

1.Vitreous hemorrhage associated with detached retina2.Long-standing vitreous hemorrhage with duration

greater than 2-3 months.3.Vitreous hemorrhage associated with rubeosis.4.Vitreous hemorrhage associated with hemolytic or

ghost-cell glaucoma.5.Vitrectomy for isolated vitreous hemorrhage (eg,

without retinal detachment) may be performed before 2-3 months in patients with juvenile-onset diabetes, patients with bilateral vitreous hemorrhage, children in the amblyogenic age range, and/or when retinal traction is suspected.

FOLLOW UP: Initially, patients with vitreous hemorrhage

are monitored daily for 2-5 days to rule out retinal tear or detachment

every 1-2 weeks for spontaneous clearing. dense vitreous hemorrhage persists without

known underlying cause, a B-scan ultrasonography should be serially performed.