basic etiology and management of vitreous hemorrhage

1. Dr Pooja Choudhary
III yr JR(M.S. Opht0)
MDM Hospital

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

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

4.  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

5.  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

6. Mechanisms of Vitreous Hemorrhage
1.Abnormal Vessels
 Diabetic 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

7. CRVO Eales disease

8. NPDR PDR

9. 2.Rupture of Normal Vessels
 Retinal 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)

10. 3.Blood From Adjacent Source
 Macroaneurysm (0.6–7 percent)
 Age-related macular degeneration (0.6–4 percent)
Wet ARMD

11. Others causes you must look :
1.Ruptured arterial macroaneurysm .
2. coat’s disease.
3.ROP
4.retinal capillary angioms of Von Hippel Lindau
syndrome.
5.Congenital prepapillary vascular loop
6.Retinal cavernous hemangiomas

12. 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

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

14. 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

15. Workup
1. 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.

16. 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.

17. B-scan : is of great
importance
1.To rule out any tumour
/mass
2.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

18.  Treatment
 directed at the underlying cause, if known
 unreliable/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
.

19. 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.

20. 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 surgery
3.Proliferative retinal vascular diseases are treated with
laser photocoagulation or cryotherapy (when there is
no view of the retina).

21. Indications for surgical removal of the vitreous blood by
pars plana vitrectomy include the following:
1.Vitreous hemorrhage associated with detached retina
2.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.

22. 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.