Vitreous Hemorrhage in Emergency Medicine Clinical Presentation

  • Author: Gregory L Larkin MD, MD, MS, MSPH, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 20, 2011
 

History

Patient history, both medical and ocular, is essential in the emergency department evaluation of vitreous hemorrhage. Assessing and documenting the patient's vision prior to symptoms of hemorrhage is crucial. Underlying eye disease often provides clues to the cause of hemorrhage.

Patients with acute vitreous hemorrhage frequently seek emergency care because the loss of vision is dramatic. Visual acuity varies with the degree of hemorrhage, but even 10 microliters of blood can reduce vision to hand motion.

The patient recognizes minimal bleeding as new multiple floaters, visual haze, smoke, shadows, or cobwebs. Moderate hemorrhage may be described graphically as 1 or more dark streaks that subsequently break up into numerous, minute black spots. Dense hemorrhage can reduce vision to the light perception level.

Patients may report visual obstruction changes with eye or head movement and the tendency to try to look around the obstruction. In the absence of trauma, no pain is experienced with vitreous hemorrhage.

Next

Physical

A complete eye examination is indicated for both eyes. Examining the uninvolved eye may provide clues to the underlying cause of hemorrhage in the involved eye, such as dot and blot hemorrhages of diabetic retinopathy, drusen and exudate in macular degeneration, or venous dilation in hypertensive disease and vein occlusion. Some etiologies, such as SAH, may present bilaterally.

Once diagnosis of vitreous hemorrhage is confirmed, ophthalmologic consultation is indicated to determine the causes and appropriate intervention.

A complete eye examination includes the following:

  • Test visual acuity in both eyes.
  • Test pupil response.
  • Slit lamp examination: Fresh blood is identified readily by adjusting the slit beam to a tangential position and viewing the anterior vitreous directly behind the lens. Retrolenticular hemorrhage may be easily visualized.
  • Direct ophthalmoscopy: With direct ophthalmoscopy, a variable loss of fundus detail is present with floating debris, which often is recognized as red debris. Old hemorrhage undergoes syneresis (ie, degenerates), loses color (turns orange or whitish yellow), and settles inferiorly. Resolving hemorrhage may leave an iridescent spot or refractile hemosiderin copper-colored granules.
  • Indirect ophthalmoscopy: Use of this technique usually requires expert training and is best left to the trained ophthalmologist. Indirect ophthalmoscopy is the only way to evaluate the eye for peripheral abnormalities; this permits stronger magnification, illumination, and stereopsis. Scleral depression or use of a 3-mirror lens is required to exclude retinal tears of the periphery.

Preretinal (ie, subhyaloid) hemorrhage commonly is observed on the fundus upon examination of shaken infants and has a characteristic meniscus that changes direction with head position.

Previous
Next

Causes

  • Vitreous hemorrhage risk factors include diabetic retinopathy, branch or central retinal vein occlusion, retinal tears with or without detachment (especially in high myopia), PVD, and retinal artery occlusion (see Frequency).
  • Trauma, including shaken baby syndrome in infants, is the leading cause of vitreous hemorrhage in young individuals.
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Gregory L Larkin MD, MD, MS, MSPH, FACEP  Professor, Department of Emergency Medicine, Yale University School of Medicine

Gregory L Larkin MD, MD, MS, MSPH, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Society for Bioethics and Humanities, Association for the Advancement of Automotive Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Richard S Krause, MD  Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Douglas Lavenburg, MD  Clinical Professor, Department of Emergency Medicine, Christiana Care Health Systems

Douglas Lavenburg, MD is a member of the following medical societies: American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Spraul CW, Grossniklaus HE. Vitreous Hemorrhage. Surv Ophthalmol. Jul-Aug 1997;42(1):3-39. [Medline].

  2. Litten M. Uber cinige vom allgemein-klinischen Standpunkt aus interessante Augenveranderungen. Berl Kline Wochenscher. 1881;18:23-27.

  3. McCarron MO, Alberts MJ, McCarron P. A systematic review of Terson's syndrome: frequency and prognosis after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry. Mar 2004;75(3):491-3. [Medline].

  4. Yoonessi R, Hussain A, Jang TB. Bedside ocular ultrasound for the detection of retinal detachment in the emergency department. Acad Emerg Med. Sep 2010;17(9):913-7. [Medline].

  5. Chew EY, Klein ML, Murphy RP, et al. Effects of aspirin on vitreous/preretinal hemorrhage in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study report no. 20. Arch Ophthalmol. Jan 1995;113(1):52-5. [Medline].

  6. Effects of aspirin treatment on diabetic retinopathy. ETDRS report number 8. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. May 1991;98(5 Suppl):757-65. [Medline].

  7. Flynn HW, Chew EY, Simons BD, et al. Pars plana vitrectomy in the Early Treatment Diabetic Retinopathy Study. ETDRS report number 17. The Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. Sep 1992;99(9):1351-7. [Medline].

  8. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 1998:1089-119.

  9. Rosen P, Baker FJ, Barkin RM. Emergency Medicine: Concepts and Clinical Practice. 1988:1033-49.

  10. Rosen P, Barkin RM, Sternbach GL. Essentials of Emergency Medicine. 1991:553-66.

  11. Tintinalli JE, Krome RL, Ruiz E. Emergency Medicine: A Comprehensive Study Guide. 1992:833-40.

 
Previous
Next
 
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.