Vitreous Hemorrhage Clinical Presentation

Updated: Sep 07, 2018
  • Author: Brian A Phillpotts, MD, MD; Chief Editor: Douglas R Lazzaro, MD, FAAO, FACS  more...
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Presentation

History

Patients with vitreous hemorrhage often present with a complaint of visual haze, floaters, cloudy vision or smoke signals, photophobia, and perception of shadows and cobwebs.

Small vitreous hemorrhage often is perceived as new multiple floaters, moderate vitreous hemorrhage is perceived as dark streaks, and dense vitreous hemorrhage tends to significantly decrease vision even to light perception.

Usually, no pain is associated with vitreous hemorrhage. Exceptions may include cases of neovascular glaucoma, severe acute ocular hypertension secondary to ghost-cell glaucoma, or trauma.

Ophthalmoscopic examination reveals blood within the vitreous gel and/or the anterohyaloid or retrohyaloid spaces.

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Physical

Vitreous hemorrhage within the Berger space tends to settle and form a crescent-shaped pool overlying the hyaloideocapsular ligament.

In the Cloquet canal, vitreous hemorrhage tends to delineate its inferior border and that within the retrohyaloid space caused by vitreous detachment may accumulate as a meniscus at the inferior vitreoretinal boundary, boat-shaped hemorrhage.

Similarly, vitreous hemorrhage within the space between the internal limiting and the nerve fiber layer may resemble that within the retrohyaloid space, except that the blood does not shift with change in the head position as may be the case with subhyaloid hemorrhage.

Note that sub–internal limiting membrane hemorrhage usually implies an intraretinal source of bleeding, whereas subhyaloid hemorrhage usually implies a source of bleeding anterior to the retina.

Vitreous hemorrhage due to Terson syndrome, anemia, Valsalva retinopathy, shaken baby syndrome, and retinal macroaneurysm rarely breaks through the internal limiting membrane or into the subretinal space.

Vitreous hemorrhage due to diabetic retinopathy and branch retinal vein occlusion starts anterior to the internal limiting membrane and bleeds into the vitreous.

The hemorrhage tends to progress through a distinct change in color from red to pink to orange to yellow white. In sub–internal limiting membrane hemorrhage, especially in sickle cell retinopathy, iridescent spots may develop with resolution of these hemorrhages. Iridescent spots are refractile, copper-colored granules representing hemosiderin-laden macrophages subjacent to the internal limiting membrane. These spots are unusual in hemorrhages anterior to the internal limiting membrane as in diabetic retinopathy or branch retinal vein occlusion.

Because of the presence of focal attachment between the internal limiting membrane and the retina at the central fovea area and peripheral to the posterior pole, sub–internal limiting membrane hemorrhage tends to spare the central fovea. Some attachment of the vitreous at the fovea may exist, which may explain why some preretinal hemorrhages spare the fovea.

On the other hand, bleeding into the vitreous body shows no definite border. In massive vitreous hemorrhages, a mild afferent pupillary defect may be observed.

Detailed history and physical examination are very important. History of any ocular or systemic diseases (particularly those mentioned above) as being associated with vitreous hemorrhage, including trauma, should be elicited.

Complete eye examination should be performed, including slit lamp examination (with gonioscopy to determine angle and iris neovascularization), intraocular pressure, and dilated fundus examination of both eyes with indirect ophthalmoscopy.

Scleral depression may be performed in some instances of spontaneous vitreous hemorrhage if a view of the peripheral retina is possible. In general, scleral depression is not recommended until 3-4 weeks after traumatic, vitreous hemorrhage. Scleral depression may detect a flap retinal tear.

In the absence of a view of the retina, B-scan ultrasonography is used to ascertain the presence of retinal detachment, retinal tear, intraocular foreign body, or intraocular tumor.

In some cases, the cause of vitreous hemorrhage may be ascertained by a fluorescein angiogram, if the clarity of the media allows.

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Causes

See Pathophysiology.

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