Vitreous Hemorrhage by Rajesh

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MajorReview Vitreous Hemorrhage

Address for Correspondance: Vitreoretinal Services, Alsalama Eye Hospital, Perinthalmanna

Rajesh.P MD, Dheeresh .K MS, Safarulla M.A MS, Shaji Hussain MS.

Vitreous hemorrhage is dened as bleeding into the space

outlined by the internal limiting membrane of the retina

posteriorly and posteriolaterally, the non pigmented

epithelium of the ciliary body laterally and the lens zonules

and the posterior lens capsule anteriorly1.The incidence

of vitreous hemorrhage is approximately seven cases per

100000 population2.

Causes of Vitreous Hemorrhage

The most common causes of vitreous hemorrhage are

proliferative diabetic retinopathy (31-54%), vascular

occlusions (4-16%), retinal tear (11-44%) and trauma (12-

19%)1. In young the most common cause is trauma1.

Vitreous hemorrhage can also occur in CNVM, polypoidal

choroidovasculopathy, retinal macro aneurysm, secondary

to subarachnoid hemorrhage (Terson’s syndrome) and

various vasculopathies causing neovascularisation.Bleeding

from a vasularised snow bank can occur in parsplanitis. Other

rare cases are blood dyscrasias, Valsalva retinopathy, and

intraocular tumors3.

In newborn the causes are trauma during spontaneous

vaginal delivery, ROP, and shaken baby syndrome3. In

children trauma is the most common cause3

. Retinoblastoma,leukemia and other coagulopathies can also cause

hemorrhage in children3.

Pathophysiology

Traction exerted by vitreous on the retinal vessels, either

normal or pathologic, leads to bleeding into the vitreous gel

or the sub hyaloid space. The blood in sub hyaloid space has

a boat shape conguration.

The spontaneous rupture of a retinal macro aneurysm,

bleeding from a retinal angioma, rupture of venules in

Valsalva retinopathy etc are causes of vitreous hemorrhage

without any vitreous traction.Break through of sub retinal hemorrhage as in CNVM, PCV,

Choroidal malignant melanoma is another mechanism

responsible for vitreous hemorrhage3.

In Terson’s syndrome the hemorrhage is a result of rupture

of retinal venules due to sudden increase in intracranial

pressure2.

Course of Vitreous Hemorrhage

Spontaneous clearance of hemorrhage from vitreous cavity

can occur in conditions where there is no recurrent bleed.

Erythrocyte in the vitreous may exit through the trabecular

meshwork or may undergo hemolysis or phagocytosis

or persist in the vitreous for many years. The blood that

breaks in to the vitreous cavity clots rapidly and often

clears slowly at about 1% per day2. The clearance is faster in

vitrectomised eyes and eyes with syneretic vitreous 2 If the

hemorrhage does not clear, it may lead to hemosiderosis

bulbi, brovasular proliferation and glaucomas (hemolytic,

ghost cell , hemosiderotic glaucomas)1.

Clinical Features

Symptoms: Patients often present with sudden painless

loss of vision. The symptoms may range from oaters to

sudden black out of vision. Flashes that precede the onset of

symptoms often suggest posterior vitreous detachment with

or without retinal tear formation. Acute PVD with vitreous

hemorrhage is associated with 70% incidence of retinal

tears compared to 2-4 %incidence in acute PVD without

hemorrhage4.

Evaluation of Patients With Vitreous Hemorrhage

History of trauma, ashes, diabetes, hypertension,

dyslipidemia, and any bleeding disorders may be elicitedto establish the possible etiology of vitreous hemorrhage.

A hypertensive can develop a vascular occlusion with

proliferative changes or at times develop vitreous hemorrhage

from macro aneurysm rupture. Vision has to be recorded and

varies depending on the severity of hemorrhage.

Pupillary reaction may be normal unless there is an underlying

optic nerve or large macular lesion. Long standing retinal

detachment can also cause a RAPD.

Slit lamp examination helps to pick up iris or angle

neovasularisation which suggests an underlying ischemic

cause like proliferative diabetic retinopathy, carotid ischemiaor vascular occlusion .Keratic precipitates may suggest

an inammatory etiology. Tell tale signs of trauma may be

picked up during slit lamp examination. An iris hole or a

localized cataract may suggest an intra ocular foreign body.

Dilated fundus examination will be helpful to establish the

cause of vitreous hemorrhage when hemorrhage is not

dense. Examination of the other eye is important, since

conditions like diabetic retinopathy, retinal vasculitis, FEVR,

retinoschisis are bilateral. Unilateral hemorrhage in the

absence of ndings in the other eye could be due to trauma,



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posterior vitreous detachment with or without retinal tear,

vascular occlusion, tumors, CNVM or PCV. In patients with

history of ashes, if the media clarity permits, attempt should

be made to locate a tear.

In those patients where the posterior segment details are

not clear an ultra sound scan is indicated. This helps to pickup an underlying retinal tear, posterior vitreous detachment,

retinal detachment and tumors .It has to be remembered that

fresh dispersed hemorrhage in the vitreous may be picked

up only by scanning at a high gain5. Clotted hemorrhage can

be seen as opacities with varying reectivity in the vitreous

cavity, denser inferiorly. Associated sub hyaloid hemorrhage

is seen as multiple dot echoes between the retina and

posterior hyaloid5. In an elderly individual with drusens in

the fellow eye, a mound at the macula detected on the scan

of the eye with vitreous hemorrhage suggests a CNVM5. PCV

associated vitreous hemorrhage may be characterized by

a focal choroidal thickening without excavation or acoustichollowing with associated low reective echoes of dispersed

VH, or diuse choroidal thickening and low-intensity echoes

of dispersed hemorrhage on either side of the retinal spike,

often without vitreous detachment spike6. In cases of non

clearing hemorrhages the scans should be repeated every

2-3 weeks to rule out the development of any retinal break

or retinal detachment .In vascular retinopathies, detection of

tractional detachment involving the macula is an indication

for early surgery. In cases of traumatic vitreous hemorrhage

sonography also helps in detecting an intraocular foreign

body. CT scan may be done to rule out an intraocular foreign

body if foreign body is clinically suspected and is not seen on

ultrasonography.

Management

Management of vitreous hemorrhage depends on the

etiology, the media clarity, the other eye status, duration of

hemorrhage, presence of NVI, NVA etc. The options available

in the management of vitreous hemorrhage are,

(1) Observation

(2) Laser photocoagulation

(3) Intravitreal anti VEGF injections

(4) Pars plana vitrectomy.

(5) Enzymatic vitreolysis

Observation

All vitreous hemorrhages are not surgical emergencies. If

there is no associated retinal detachment, retinal break, intra

ocular tumor, neovascularisation of the iris or the angle,

observation can be tried initially. If the retina is attached the

patient is asked to rest with the head in an elevated position

and is reevaluated at 3-4 weeks intervals3 .Retinal detachment

has to be ruled out with the help of ultrasonography at each

visit, if the retinal details cannot be made out .The blood

gravitates to the bottom of the vitreous cavity with rest and

the underlying cause which becomes visible is then treated

. Observation can be continued for up to 2-3 months3.

Laser Photocoagulation

Where the primary cause is visible through the hemorrhage,

at presentation, or after a period of observation (like PDR

changes, vascular occlusion), prompt LASER treatment may

help in clearing of vitreous hemorrhage. The successful

resolution of the primary cause prevents rebleeding and the

blood already in the vitreous cavity will be taken care of by

the natural mechanisms. The posterior vitreous detachment

induced retinal breaks also have to be surrounded by

conuent laser to prevent retinal detachment. The LASER

treatment through hemorrhage may require an indirect

LASER delivery system.

Intravitreal Anti VEGF Injections

Intravitreal Bevacizumab (avastin) has been used to treat

vitreous hemorrhage secondary to vascular retinopathies

like PDR, vascular occlusion, Eale’s disease8, 9 etc. This may

result in the resolution of neovascularisation preventing

further bleeding and improvement in the media clarity to

allow LASER treatment7. But the injection can also worsen

the tractional detachments due to contraction of the

bro vascular proliferations associated with the vascular

retinopathies8, 11. Hence if the hemorrhage does not clear,

or the retinal status seems to be under threat, immediate

surgery as early as within 7 days of injection is advised10

.

Pars Plana Vitrectomy

Urgent vitrectomy is warranted when vitreous hemorrhage

is associated with retinal detachment, CNVM, PCV, and any

condition which is likely to progress fast if left untreated3.

Traumatic vitreous hemorrhage with intraocular foreign

body is another indication for emergency vitrectomy.

Bilateral vitreous hemorrhage where the patient wants early

visual rehabilitation is also an indication for early surgery.

Vitrectomy is indicated for all cases of nonclearing vitreous

hemorrhage. Type 1 diabetic patients with vitreous

hemorrhage are reported to have a poorer prognosis withdelayed vitrectomy by Diabetic Retinopathy Vitrectomy

Study12. Type 1 diabetics are advised surgery within 1

month of onset of symptoms; type 2 patients may wait up

to 2-3 months for spontaneous clearance before undergoing

surgery2. During the period of observation serial monitoring

with ultrasound to rule out a tractional retinal detachment

involving the macula is recommended. With the widespread

use of anti VEGF agents these guidelines are not strictly

adhered to and more and more patients are receiving

intravitreal injections and under going early surgery 10,13,14,15.

Rajesh P et al - Vitreous Hemorrhage



Vol. XXIII, No.3, Sept. 2011

194

Kerala Journal of Ophthalmology

A Meta analysis on the role of preoperative intravitreal

avastin on the surgical out comes in diabetic retinopathy has

observed that there is a signicant reduction in the incidence

intraoperative bleeding and frequency of endodiathermy

in the IVB (intra vitreal Bevacizumab/avastin) pretreatment

group than in the vitrectomy alone group16

. The IVBpretreatment group took signicantly less surgical time than

the control group16. It also reduced the incidence of post

operative recurrent hemorrhage with better visual outcomes

compared to vitrectomy alone group16. Also the use of 23 g

suture less vitrectomy systems with high speed vitrectors

with ports close to the tip helping complete dissection of the

membranes obviating the need for extra instrumentation,

wide angle lenses, and chandelier light systems allowing

bimanual dissection have all made the surgical results better

and hence a more aggressive approach is being practiced.

Branch retinal vein occlusion may lead to vitreous

hemorrhage and if the blood does not clear up in 2-4 months,surgery is indicated .Early surgery may be required if there

is a tractional detachment threatening the macula. Vascular

retinopathies in young patients like Eale’s disease also

require vitrectomy if the hemorrhage does not clear in 2-3

months. But as for diabetic vitreous hemorrhage intravitreal

anti VEGF injections and early surgery are being done for

these indications also8, 9.17.

In traumatic vitreous hemorrhage with no intraocular

foreign body or retinal detachment, surgery may be delayed

up to 2-3 weeks for the posterior vitreous detachment

(PVD) to develop3. Similarly one can wait for posterior

vitreous detachment to develop before vitrectomy, in eyeswith Terson’s syndrome, post cataract surgery vitreous

hemorrhage (not due to retinal breaks or accidental globe

perforation) and vitreous hemorrhage in bleeding diathesis3.

This helps to avoid the step of induction of PVD which may

be dicult especially if the patient is young.

Enzymatic Vitreolysis -Intravitreal Hyaluronidase

Ovine Hyaluronidase (vitrase) when given intravitreally

facilitates the clearance of vitreous hemorrhage by inducing

liquefaction of the vitreous which allows for red blood cell

lysis and phagocytosis18. Results from randomized control

trials have shown that single intravitreal injection of ovine

Hyaluronidase helped in visualization of the underlying

pathology and treatment of the underlying pathology in

a signicant number of patients receiving the injection

compared to the placebo19. Also > 3 line improvement in BCVA,

hemorrhage density reduction was achieved in a signicant

proportion of patients receiving vitrase injection19. These

injections are considered safe except for the occurrence of

mild iritis20. A model based on reduction in total hemorrhage

point score has been developed to predict the patients who

are most likely to have the vitreous hemorrhage cleared by a

single intravitreous injection of Ovine Hyaluronidase18.

Recurrent Hemorrhage afterVitrectomy For Diabetic Vitrectomy

Post operative vitreous hemorrhage following diabetic

vitrectomy has an incidence varying between 29-75%21

. Thecauses of early vitreous hemorrhage are dispersed blood

from the peripheral vitreous skirt, oozing from the cut end

of vessels, hypotony etc22. This may clear on its own in

2-3 weeks and may be managed by uid air exchange if it

persists. Intraocular tamponade with 10% C3F8 in vitrectomy

for proliferative diabetic retinopathy has been reported to

be associated with reduction of early postoperative vitreous

hemorrhage 23. Preoperative avastin helps in diabetic

vitrectomy and reduces the need for extensive segmentation

and delamination , decreasing the chance of signicant early

vitreous hemorrhage 13.Another study comparing eect

of intravitreal avastin before surgery with intra operative

avastin at the end of surgery has reported that, the incidence

of early post operative vitreous hemorrhage( occurring in

less than 4 weeks)is 10.8 % in group treated with avastin at

the end of vitrectomy , compared to 22.8 % in pre surgery

avastin group 24.

Late recurrent hemorrhage is due to brovascular ingrowth

(FVIG) at the sclerotomy sites, anterior hyaloidal proliferation,

neovascularisation of residual brovascular tissue; angle or

iris22 .This can be treated with intravitreal Bevacizumab28,

vitreous lavage with additional laser, anterior retinal

cryothreapy (ARC) and in severe cases dissection of the

vascular membranes followed by laser cryo and tamponade25.

Fibrovascular ingrowth has been reported to be the cause of

5725-87.5% 27 of recurrent hemorrhage. It is often indicated by

a dilated episcleral vessel entering the previous sclerotomy

site 25. UBM of the sclerotomy site may show a large and

low reecting trapezoidal image indicating its presence26.

Anterior peripheral retinal cryotherapy combined with

cryotherapy of sclerotomy sites in patients undergoing

diabetic vitrectomy has been advised for inhibition of FVIG

and prevention of recurrent vitreous hemorrhage27.

With early detection and timely treatment of conditions

predisposing to vitreous hemorrhage, the incidence

of hemorrhage can be reduced. Even in those patients

developing hemorrhage, prompt evaluation and

implementation of proper treatment can go a long way in

providing better visual results

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Vitreous Hemorrhage by Rajesh