Basics
Description
Vitreous hemorrhage is a secondary diagnosis; identification of a specific cause is necessary for successful treatment:
- 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:
- Intraocular tumor
- Prematurity
- Congenital retinoschisis
- Pars planitis
- Child abuse:
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
History
- Ocular or systemic diseases
- Trauma
Physical Exam
Fundoscopic exam:
- Absent red reflex
- No view of the fundus
- Acute:
- RBCs in anterior vitreous
- Chronic:
- Yellow appearance from hemoglobin breakdown
Essential Workup
- History with special attention to pre-existing systemic disease and trauma
- Complete ocular exam including:
- Slit lamp
- Tonometry
- Dilated fundoscopic exam
Diagnosis Tests & Interpretation
Lab
- CBC
- PT/PTT/INR if indicated
- Electrolytes, BUN, creatinine, glucose
Imaging
- 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
Diagnostic Procedures/Surgery
If nontraumatic, scleral depression
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)
Treatment
Pre-Hospital
Protect the eye from trauma or pressure:
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 diseases
- Repair of retinal detachments
- Surgical vitrectomy is needed for:
- Blood that does not clear with time
- VH from retinal detachement
- Associated neovascularization
- Hemolytic or ghost-cell glaucoma
Follow-Up
Disposition
Admission Criteria
Retinal break or detachment
Discharge Criteria
Retinal break or retinal detachment must be excluded as cause of hemorrhage.
Followup Recommendations
Re-evaluation daily for 2 " 3 days; if etiology is still unknown, B-scan US every 1 " 3 wk.
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 ‘n JA, Mu ±oz-Hern ‘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)