Vitreous Hemorrhage: Causes, Symptoms, and Management

Vitreous hemorrhage (VH) is blood in the vitreous cavity, usually from retinal neovascularization or trauma. It causes sudden vision loss and requires urgent evaluation to identify and treat the underlying cause.

Common Causes

• Proliferative Diabetic Retinopathy (PDR): #1 cause in working-age adults. Neovascularization → fragile vessels bleed.
• Posterior Vitreous Detachment (PVD): Traction on retinal vessels (especially with anticoagulation).
• Retinal Tear/Detachment: Vessel avulsion at tear edge.
• Retinal Vein Occlusion (CRVO/BRVO): Neovascularization secondary to ischemia.
• Wet AMD: Subretinal/choroidal neovascularization breaking through.
• Ocular Trauma: Blunt or penetrating.
• Terson Syndrome: VH with subarachnoid hemorrhage.
• Retinal Macroaneurysm, Vasculitis, Tumors (retinoblastoma, melanoma).

Symptoms

• Sudden painless vision loss (floaters, "cobwebs," "ink swirling," darkness).
• Vision from 20/20 to light perception only, depending on blood volume.
• No pain (unless trauma or acute angle closure).

Evaluation

• History: Diabetes, hypertension, anticoagulants, trauma, sudden onset.
• Exam: Visual acuity, pupils, IOP, slit-lamp (cells/flare), dilated fundus (if view).
• B-scan Ultrasound: Essential if media opacity prevents fundus view — detects retinal detachment, tumor, vitreous organization.
• OCT: If macula visible (macular edema, hemorrhage).
• FA/OCTA: For neovascularization assessment when media clears.

Management

Observation

• Small VH, known cause (e.g., PVD in anticoagulated patient), attached retina on ultrasound.
• Head elevation (30–45°), eye shield, avoid anticoagulants if possible.
• Most clear spontaneously over weeks–months.

Laser Photocoagulation

• Panretinal photocoagulation (PRP) for PDR, ischemic CRVO — once media clears enough.
• Barrier laser for retinal tears.

Anti-VEGF Injections

• Bevacizumab, ranibizumab, aflibercept — regress neovascularization, accelerate clearance.
• Often combined with PRP for PDR.

Pars Plana Vitrectomy (PPV)

• Indications: Non-clearing VH (>3 months), VH with retinal detachment, dense VH preventing laser/anti-VEGF, Terson syndrome, diagnostic uncertainty.
• High success rate; visual recovery depends on underlying pathology.

Key Point

New VH in a diabetic = presume PDR until proven otherwise. Urgent retina referral. Don't delay—proliferation progresses.