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 a small amount of blood can reduce vision to hand motion.
The patient recognizes minimal bleeding as new multiple floaters, visual haze, smoke, shadows, cobwebs, or visual blurring. 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 presenting with acute posterior vitreous detachment commonly have symptoms of new-onset floaters with or without accompanying light flashes in the periphery of their vision. It is impossible to ascertain whether the floaters represent vitreous hemorrhage or merely a detached posterior vitreous without examination of the vitreous.
Patients may report that the visual obstruction changes with eye or head movement and that they may tend to attempt to look around the obstruction. In the absence of trauma, no pain is experienced with vitreous hemorrhage unless it is accompanied by acute angle closure glaucoma from the blood-filled vitreous pushing the iris-lens diaphragm forward.
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 the dot and blot hemorrhages seen with diabetic retinopathy, drusen and exudate in macular degeneration, or venous dilation in hypertensive disease and vein occlusion. Some etiologies, such as SAH, may manifest as bilateral vitreous hemorrhage.
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:
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Visual acuity testing of each eye individually
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Pupillary response testing
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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.
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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.
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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 retinal abnormalities. Scleral depression is required to exclude retinal tears of the periphery.
Preretinal (i.e., subhyaloid) hemorrhage commonly is observed on the fundus upon examination of shaken infants and has a characteristic meniscus that changes direction with head position.
Causes
Vitreous hemorrhage risk factors include diabetic retinopathy, branch or central retinal vein occlusion, retinal tears with or without detachment (especially in high myopia), posterior vitreous detachment, and retinal artery occlusion.
Trauma, including shaken baby syndrome in infants, is the leading cause of vitreous hemorrhage in young individuals.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
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Vitreous hemorrhage. Courtesy of UT Southwestern Medical School, Department of Ophthalmology.
