By Ralph D. Levinson, MD
This retrospective study found that spontaneous pediatric vitreous hemorrhage has a diverse etiology, with vasculitis being the most common cause. A comprehensive evaluation, both systemic and ocular, is required to ensure that vision- and life-threatening conditions are not missed.
The authors reviewed the charts of children who presented with spontaneous vitreous hemorrhage without a clear-cut etiology over a 10-year period at an eye institute in India. The study’s data included 124 eyes of 76 children ranging in age from four months to 17 years. The minimum follow-up was one month, and the mean was 28 months.
A sizeable number of eyes that presented with what appeared to be spontaneous hemorrhage in fact had intraocular inflammation, most commonly vasculitis (34.6 percent). Therefore, a likely cause of spontaneous hemorrhage is retinal vasculitis, especially in adolescents. It’s also notable that this was a population in India, which implies other diagnostic possibilities that would be much less common in the United States, such as Eales’ disease. Nonetheless, this study reminds us that retinal vasculitis can present as spontaneous hemorrhage.
Forty-eight patients had bilateral vitreous hemorrhage. The most common presenting complaints were diminished vision (96.45 percent) and behavioral changes (87.24 percent). The mean baseline BCVA was 2.25 ± 1.11 logMAR.
The highest rate of vasculitis was seen in subjects older than 10 years. Of the 69 eyes in that group, 34 had vasculitis. The authors note that of the 30 patients with vasculitis, 17 had unilateral vitreous hemorrhage and 11 had signs suggestive of vasculitis in the other eye, but timely laser photocoagulation and/or oral immunosuppressive therapy helped prevent a similar occurrence in the fellow eye.
Hematologic disorders constituted the next major group of etiologic diagnosis of vitreous hemorrhage (21 patients, 27.4 percent). These included sickle cell anemia (5 patients), leukemia (9 patients), anemia (3 patients) and thrombocytopenia (4 patients). These were managed in consultation with the treating hematologist.
Five patients had retinal breaks without retinal detachment; three presented with a sudden onset of floaters and two presented with a recent onset of flashes. Two patients had high myopia. One patient had an associated lattice.
Patients were given medical therapy (topical and/or systemic) or underwent laser photocoagulation (29 percent) and/or surgery (55.6 percent). Twenty-nine eyes (23.3 percent) did not require any intervention.
The mean number of surgeries was 1.89 ± 1.45 (range, one to four surgeries). The mean final visual acuity was 0.76 ± 0.58 logMAR and was significantly better than baseline visual acuity (P < 0.001). The best anatomic and visual outcomes were seen in vasculitis, whereas congenital disorders, such as retinoschisis, produced the worst.
The authors note that the number of infants with a vitreous hemorrhage of unknown etiology was more than twice that in the 1 to 10-year age group and five times that in the older age group. This points to the difficulty in eliciting appropriate history and clinical signs and symptoms in very young children. They also stress the importance of bilateral dilated fundus examination, under anesthesia if required. Appropriate intervention, such as diagnostic vitreous biopsies, proved useful in patients not only in ruling out infection etiology in suspicious cases, but also in histopathologic confirmation of inflammatory disorders, such as tuberculosis.