A common cause of emergency visits to ophthalmology offices is sudden vision loss due to vitreous hemorrhage not associated with trauma to the eye. In adults, the most common causes include proliferative diabetic retinopathy (see Chapter 5), PVD, central retinal vein occlusion, and retinal neovascularization from a variety of causes (see Chapter 7, Table 7-2). Bleeding can be exacerbated by the use of systemic anticoagulants, so physicians need to be aware of the systemic medications the patient is taking. In cases of vitreous hemorrhage associated with an acute PVD, retinal tears are found in approximately 50%–70% of eyes and clinical retinal detachment in 8%–12%. In children, X-linked hereditary retinoschisis and pars planitis are common causes of vitreous hemorrhage; however, trauma must always be considered in the differential diagnosis (see Chapter 18).
In most cases of vitreous hemorrhage, the underlying cause can be determined by obtaining a history or on retinal examination. If the hemorrhage is too dense to permit indirect ophthalmoscopy or biomicroscopy, suggestive clues can be obtained from examination of the fellow eye. Diagnostic echography should be performed to detect any tractional tear (often superotemporally) and to rule out retinal detachment or tumor. Bilateral eye patching with bed rest for a few hours to several days, with the head of the bed elevated, may permit the intrahyaloid and retrohyaloid blood to settle, allowing for a better view of the posterior segment. If the etiology still cannot be established, the ophthalmologist should consider frequent reexamination with repeat echography until the cause is found. Alternatively, prompt diagnostic vitrectomy in nondiabetic patients can be considered and may help prevent progression of a retinal tear to retinal detachment. Ghost cell glaucoma can result from long-standing vitreous hemorrhage. Early intervention should be considered in monocular patients with vitreous hemorrhage. In addition, surgical intervention should be considered in patients whose hemorrhage does not clear.
El-Sanhouri AA, Foster RE, Petersen MR, et al. Retinal tears after posterior vitreous detachment and vitreous hemorrhage in patients on systemic anticoagulants. Eye (Lond). 2011;25(8):1016–1019.
Sarrafizadeh R, Hassan TS, Ruby AJ, et al. Incidence of retinal detachment and visual outcome in eyes presenting with posterior vitreous separation and dense fundus-obscuring vitreous hemorrhage. Ophthalmology. 2001;108(12):2273–2278.
Witmer MT, Cohen SM. Oral anticoagulation and the risk of vitreous hemorrhage and retinal tears in eyes with acute posterior vitreous detachment. Retina. 2013;33(3):621–626.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.