Vitreous Haemorrhage - what causes it?

Hemoragia vitreană este o afecțiune oculară care se manifestă prin simptome precum vedere încețoșată, pete în câmpul vizual și distorsiuni ale percepției culorilor. Cauzele hemoragiei vitreene pot include traumatisme oculare, diabet sau degenerare maculară. Pentru a gestiona această problemă, consultul oftalmologic este esențial pentru diagnostic și intervenție precoce.

Tratamentul hemoragiei vitreene poate implica monitorizare, administrarea de medicamente sau chiar intervenție chirurgicală. Obține o evaluare oftalmologică pentru a discuta opțiunile de tratament și pentru a îmbunătăți rezultatele pe termen lung, minimizând complicațiile asociate cu hemoragia vitreană.

1. What is Vitreous Haemorrhage?

Vitreous haemorrhage is a relatively common cause of acute vision loss and is the partial or total filling of the vitreous cavity with blood. Vitreous haemorrhage causes painless but substantial loss of vision. Although the diagnosis of vitreous hemorrhage is often simple to establish on fundus examination or ocular ultrasound, further investigation may be required to determine the underlying etiology.

2. What causes vitreous haemorrhage?

The three most common causes of vitreous hemorrhage are:

retinopatie diabetică proliferativă
posterior vitreous detachment with or without retinal rupture
eye trauma

Less common causes of vitreous hemorrhage include:

retinal vein occlusions,
choroidal tumours or choroidal neovascularisation
blood dyscrasias/coagulation disorders
neovascular age-related macular degeneration
retinal vasculitis
retinal arterial aneurysms
subarachnoid haemorrhage (Terson's syndrome)
Valsalva retinopathy

3. What are the risk factors?

Diabetes - Poorly controlled diabetics with advanced organ damage, such as proliferative diabetic retinopathy, are at high risk.
Hypertension
Smoking
Posterior vitreous detachment with or without a retinal tear, which is a physiological aging process of the eye, can induce vitreous hemorrhages in older, nondiabetic individuals
Eye and brain trauma - The use of anticoagulants and antiplatelet agents is unlikely to cause spontaneous vitreous hemorrhage, but may increase the risk of bleeding. Patients with systemic clotting disorders and blood dyscrasias, such as leukemia and thrombocytopenia, may have an increased risk of vitreous hemorrhage.

4. Mechanisms leading to vitreous haemorrhage

Extravasation of blood into the vitreous cavity is generally caused by two basic mechanisms: rupture of normal vessels by mechanical force and haemorrhage from pathological structures.

Vitreous haemorrhage leads to blood clots and has an elimination rate of about 1% per day. Erythrocytes exit through the trabecular meshwork, undergo haemolysis, phagocytosis or persist in the vitreous body for several months.

5. What can we do to prevent vitreous haemorrhage, especially if we are at risk for it?

Attention should be directed towards controlling risk factors for systemic vascular disease, such as diabetes, high blood pressure and smoking.

Frequent ophthalmological check-ups, with examination of the dilated fundus to detect retinopathy lesions and initiation of therapeutic intervention.

Eye protection should be worn during activities that may cause eye trauma, glasses, helmets.

6. What are the signs and symptoms suggestive of a vitreous haemorrhage?

The patient accuses and describes:

sudden, painless visual loss
sight unseen
a spot or a reddish tinge
Floating flakes in the visual field
shadows or "cobwebs"

Symptoms may worsen in the morning if blood settles on the macula (centre of vision) during the night. Personal pathological history of diabetes mellitus, hypertension, trauma, previous retinal disease or eye surgery guides us in making the diagnosis.

Acuitatea vizuală variaza în funcție de localizarea, dimensiunea și gradul hemoragiei vitreene. În cazurile severe, pacienții pot avea acuitate vizuală redusă semnificativ și/sau defecte ale câmpului vizual. Examinarea cu biomicroscopul evidențiază celule roșii de sânge în vitrosul anterior. Trebuie evaluata prezența rubeozei irisului și determinata presiunea intraoculara. Pentru determinarea posibilelor neovase situate in unghiul irido-cornean, se foloseste examinarea gonioscopica. Examinarea fundului de ochi prin dilatare poate evidenția hemoragie răspândită difuz în cavitatea vitreana sau sângele se poate conforma intr-un anumit sector.

7. How is the diagnosis of vitreous haemorrhage established?

In cases where vitreous haemorrhage is very dense, the fundus structures cannot be highlighted and assessed. In this situation ocular ultrasound is used as the investigation of choice. B-scan ultrasonography or ocular ultrasonography can detect vitreous haemorrhage, posterior vitreous detachment, retinal breaks, retinal detachment, traction membranes, intraocular tumours and foreign bodies.

O alta metoda de investigatie care poate fi folosita, dar in cazuri selectate este angiografia cu fluoresceină. Ea poate fi utilă în cazurile cu hemoragie vitreeana usoara, pentru a ajuta la identificarea unei posibile neovascularizatii.

If trauma with an open lesion of the eyeball is suspected, orbital computed tomography (CT) scanning is indicated to evaluate orbital bone structures, to assess the integrity of the posterior wall of the eye (although clinically its presence is indicated by hypotony and other features) and to rule out a potential intraocular foreign body. Blood pressure should also be checked. If familial exudative vitreoretinopathy is suspected, it is useful to examine family members.

8. How is vitreous hemorrhage treated?

Treatment of vitreous hemorrhage involves both local procedures and general treatment of other possible diseases that have caused or are risk factors for vitreous hemorrhage.

Patients are advised to minimise strenuous physical activity, as an increase in blood pressure can disrupt the newly formed clot and cause new active bleeding.

It is also recommended that patients with vitreous haemorrhage keep their head elevated on the pillow to allow blood to deposit, improving their vision and allowing a more complete fundoscopic examination.

Ocular treatment can be combined with laser eye treatment and surgery.

In cases of mild vitreous haemorrhage, it can be treated with intravitreal injections and retinal laser therapy.

Neovascularisation in proliferative retinopathy, associated with diabetes or otherwise, is often treated with panretinal photocoagulation if vision is adequate. This will cause regression of the neovascularization and help reduce the risk of further hemorrhage.

Intravitreal injection of anti-VEGF agents can be used to cause regression of neovascularization in proliferative retinopathies, especially ascoagulation with panretinal laser photocoagulation.

9. Surgical treatment

Procedura chirurgicala se realizeaza prin vitrectomie posterioara minim-invaziva (25G) si este indicată pentru hemoragia vitreana densa însoțită sau nu de dezlipire sau ruptură de retina, hemoragia vitreana cauzata de corpii straini intraoculari, hemoragie asociata cu neovascularizatie iriana sau asociată cu glaucom hemolitic sau cu celule fantomă.

Vitrectomy can be both diagnostic and therapeutic. Depending on the aetiology of the haemorrhage, endolaser can also be performed intraoperatively and anti-VEGF agents can also be injected intravitreally at the end of the case. The surgeon may decide to inject a special gas that is respired after a few days postoperatively or intravitreal tamponade with silicone oil that can be kept in the eye for several months postoperatively.

10. What are my chances of recovering my sight after a vitreous haemorrhage?

The prognosis is variable depending on the aetiology, ocular status, whether the optic nerve or central retinal (macular) area is affected. Due to vitreous haemorrhage, examination of the fundus cannot be accurately performed prior to treatment, so underlying lesions cannot be properly assessed.

Patients with vitreous haemorrhage due to proliferative diabetic retinopathy or age-related macular degeneration will have a poorer prognosis compared to those with vitreous haemorrhage resulting from posterior vitreous detachment.

Descoperiți mai multe informații valoroase despre oftalmologie și sănătatea ochilor vizionând materialele realizate de experți în domeniu de pe canalul nostru de YouTube.

Dry eye syndrome

Retinal detachment

Prof. Univ. Dr. habil. Mihnea Munteanu

Prof. Univ. Dr. habil. Mihnea Munteanu is the core of the Prof. Dr. Munteanu Ophthalmology Center and also University Professor - Ophthalmology Discipline, Head of Discipline, Primary Ophthalmologist, Doctor of Medical Sciences, Qualified Doctor, FEBO. Dr. Munteanu has over two decades of experience in ophthalmology and has performed over 25.000 surgical procedures, using the most complex and up-to-date techniques in the approach, Dr. Munteanu has multiple international awards/distinctions in the field of ophthalmology and has published over 100 scientific papers in his field.

- 25th July 2022

Vitreous Haemorrhage