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Vitreous Hemorrhage, Emergency Medicine

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Vitreous Hemorrhage, Emergency Medicine

Basics

Description

Vitreous hemorrhage is a secondary diagnosis; identification of a specific cause is necessary for successful treatment:

If nontraumatic, scleral depression

Protect the eye from trauma or pressure:

Retinal break or retinal detachment must be excluded as cause of hemorrhage.

Re-evaluation daily for 2 " 3 days; if etiology is still unknown, B-scan US every 1 " 3 wk.

  • Retinal vessel tear due to vitreous separation
  • Sudden tearing of vessels due to trauma
  • Spontaneous bleeding due to neovascularization (e.g., diabetics)

Etiology

  • Blunt or penetrating trauma
  • Retinal break/tear/detachment
  • Any proliferative retinopathy
  • Diabetes mellitus
  • Sickle cell disease
  • Retinal vein occlusion
  • Eales disease
  • Senile macular degeneration
  • Retinal angiomatosis
  • Retinal telangiectasia
  • Peripheral uveitis
  • Subarachnoid or subdural hemorrhage:Terson Syndrome
  • Intraocular tumor
  • Terson Syndrome
  • Prematurity
  • Congenital retinoschisis
  • Pars planitis
  • Child abuse:Shaken-baby syndrome
  • Shaken-baby syndrome

Diagnosis

Signs and Symptoms

  • Sudden, painless unilateral loss or decrease in vision
  • Appearance of dark spots (floaters), cobwebs, or haze in visual axis:Above findings sometimes accompanied by flashing lights; floaters move with head movements
  • Blurred vision, decreased visual acuity
  • Loss of red reflex
  • Inability to visualize fundus
  • Mild afferent papillary defect
  • Above findings sometimes accompanied by flashing lights; floaters move with head movements
  • Ocular or systemic diseases
  • Trauma
  • Absent red reflex
  • No view of the fundus
  • Acute:RBCs in anterior vitreous
  • Chronic:Yellow appearance from hemoglobin breakdown
  • RBCs in anterior vitreous
  • Yellow appearance from hemoglobin breakdown

Essential Workup

  • History with special attention to pre-existing systemic disease and trauma
  • Complete ocular exam including:Slit lampTonometryDilated fundoscopic exam
  • Slit lamp
  • Tonometry
  • Dilated fundoscopic exam

Diagnosis Tests & Interpretation

  • CBC
  • PT/PTT/INR if indicated
  • Electrolytes, BUN, creatinine, glucose
  • B-scan US when no direct retinal view is possible to rule out retinal detachment or intraocular tumor
  • Fluorescein angiography to define the cause
  • CT scan/anteroposterior/lateral orbital films to rule out intraocular foreign body

Differential Diagnosis

  • Vitreitis (leukocytes in the vitreous):May include anterior or posterior uveitis
  • Retinal detachment without hemorrhage
  • Central retinal venous occlusion (CRVO)
  • Central retinal artery occlusion (CRVA)
  • May include anterior or posterior uveitis

Treatment

Pre-Hospital

  • Monitor BP

Initial Stabilization/Therapy

  • Bed rest with head of bed elevated
  • No activity resembling Valsalva maneuver (lifting, stooping, or heavy exertion)
  • Avoid NSAIDs and other anticlotting agents.

Ed Treatment/Procedures

  • Urgent ophthalmologic consultation within 24 " “48 hr is needed with treatment based on the cause of the hemorrhage; an exam is carried out by the consultant:Laser photocoagulation or cryotherapy for proliferative retinal vascular diseasesRepair of retinal detachments
  • Surgical vitrectomy is needed for:Blood that does not clear with timeVH from retinal detachementAssociated neovascularizationHemolytic or ghost-cell glaucoma
  • Laser photocoagulation or cryotherapy for proliferative retinal vascular diseases
  • Repair of retinal detachments
  • Blood that does not clear with time
  • VH from retinal detachement
  • Associated neovascularization
  • Hemolytic or ghost-cell glaucoma

Follow-Up

Disposition

Followup Recommendations

Pearls and Pitfalls

  • Be sure to consider alternate diagnoses of CRVO or CRAO.
  • Consider retinal detachment.
  • Get history of trauma and use of blood thinners.
  • Even minor bleeds require urgent ophthalmology consultation.

Additional Reading

  • Dahl ‚ AA. Vitreous Hemorrhage in Emergency Medicine. Medscape Reference. February 2013.
  • Gerstenblith ‚ AT, Rabinowitz ‚ MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
  • Hollands ‚ H, Johnson ‚ D, Brox ‚ AC, et al. Acute-onset floaters and flashes: Is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243 " “2249.
  • Leveque ‚ T. Approach to the patient with acute visual loss. In: DS Basow, ed. UpToDate. Waltham, MA: UpToDate; 2013.
  • Lorente-Ramos ‚ RM, Arm ƒ ‘n ‚ JA, Mu ƒ ±oz-Hern ƒ ‘ndez ‚ A, et al. US of the eye made easy: A comprehensive how-to review with ophthalmoscopic correlation. Radiographics. 2012;32(5):E175 " “E200.

See Also (Topic, Algorithm, Electronic Media Element)

  • Central Retinal Artery Occlusion (CRVA)
  • Central Retinal Venous Occlusion (CRVO)
  • Retinal Detachment
  • Visual Loss

Codes

ICD9

  • 250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled
  • 362.16 Retinal neovascularization NOS
  • 379.23 Vitreous hemorrhage
  • 362.81 Retinal hemorrhage
  • 362.29 Other nondiabetic proliferative retinopathy

ICD10

  • E13.39 Oth diabetes mellitus w oth diabetic ophthalmic complication
  • H35.059 Retinal neovascularization, unspecified, unspecified eye
  • H43.10 Vitreous hemorrhage, unspecified eye
  • H35.60 Retinal hemorrhage, unspecified eye
  • H35.20 Other non-diabetic proliferative retinopathy, unsp eye

SNOMED

  • 31341008 Vitreous hemorrhage (disorder)
  • 312910009 Diabetic vitreous hemorrhage (disorder)
  • 61267008 Retinal neovascularization
  • 28998008 Retinal hemorrhage (disorder)
  • 430801000124103 Proliferative retinopathy (disorder)