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Emergency and Acute Medicine: Vitreous Hemorrhage
Vitreous Hemorrhage is the presence of blood within the vitreous cavity of the eye and is considered a secondary diagnosis, meaning that identifying the underlying cause is essential for proper management. It most commonly results from retinal vessel disruption due to vitreous separation, trauma, or spontaneous bleeding from neovascularization, particularly in patients with diabetes mellitus.
The causes of vitreous hemorrhage are varied and include both traumatic and nontraumatic conditions. Trauma may be blunt or penetrating, leading to direct vessel rupture. Nontraumatic causes include proliferative retinopathies (especially diabetic retinopathy), retinal tears or detachments, retinal vein occlusion, sickle cell disease, and age-related macular degeneration. Less common causes include intraocular tumors and intracranial hemorrhage such as Terson syndrome. In pediatric patients, important considerations include prematurity, congenital retinal disorders, and nonaccidental trauma such as shaken-baby syndrome.
Clinically, patients typically present with sudden, painless, unilateral visual disturbance, ranging from mild blurring to significant vision loss. They often describe floaters, cobwebs, or a hazy visual field, sometimes accompanied by flashing lights if there is associated retinal traction. On examination, a key finding is loss of the red reflex and inability to visualize the fundus, which strongly suggests vitreous hemorrhage. A mild afferent pupillary defect may also be present depending on severity.
Evaluation requires a thorough ocular examination, including slit-lamp assessment, tonometry, and dilated fundoscopic examination. When the fundus cannot be visualized, B-scan ultrasonography is essential to assess for serious underlying pathology such as retinal detachment or intraocular tumor. Additional laboratory tests, such as complete blood count and coagulation studies, may be performed if a systemic cause is suspected. Imaging like CT may be necessary in cases of trauma to exclude intraocular foreign bodies.
Management in the emergency setting is primarily supportive. Patients should be advised to rest with the head of the bed elevated to allow blood to settle inferiorly and improve vision. Activities that increase intraocular pressure, such as heavy lifting or straining (Valsalva), should be avoided. Medications that impair clotting, such as NSAIDs and anticoagulants, should also be avoided unless medically necessary. There are no specific emergency medications required for vitreous hemorrhage itself; treatment is directed at the underlying cause.
Definitive management is guided by ophthalmology and may include laser photocoagulation or cryotherapy for proliferative vascular disease, surgical repair for retinal detachment, or vitrectomy if the hemorrhage does not resolve or is associated with complications such as neovascularization or glaucoma. Urgent ophthalmologic consultation within 24–48 hours is essential, even in seemingly mild cases, to prevent missed vision-threatening conditions.
A critical point is that vitreous hemorrhage may mimic or coexist with other serious conditions such as retinal detachment or vascular occlusions. Therefore, prompt evaluation and follow-up are necessary to prevent permanent visual impairment.
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