Major

Review

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

Vitreous hemorrhage is defined 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 (1219%)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 (Tersons 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 configuration.
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 Tersons 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, fibrovasular 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 floaters 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, flashes, diabetes, hypertension,
dyslipidemia, and any bleeding disorders may be elicited
to 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 ischemia
or vascular occlusion .Keratic precipitates may suggest
an inflammatory 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 findings in the other eye could be due to trauma,

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

Rajesh P et al - Vitreous Hemorrhage

posterior vitreous detachment with or without retinal tear,

vascular occlusion, tumors, CNVM or PCV. In patients with
history of flashes, 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 pick
up 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 reflectivity 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 acoustic
hollowing with associated low reflective echoes of dispersed
VH, or diffuse 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
confluent 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, Eales 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
fibro 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 with
delayed 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.
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Vol. XXIII, No.3, Sept. 2011

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 significant 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 IVB
pretreatment group took significantly 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 Eales 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 eyes
with Tersons 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 difficult 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 significant number of patients receiving the injection
compared to the placebo19. Also > 3 line improvement in BCVA,
hemorrhage density reduction was achieved in a significant
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
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single intravitreous injection of Ovine Hyaluronidase18.

Recurrent Hemorrhage after

Vitrectomy For Diabetic Vitrectomy
Post operative vitreous hemorrhage following diabetic
vitrectomy has an incidence varying between 29-75% 21. The
causes 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 fluid 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 significant early
vitreous hemorrhage 13.Another study comparing effect
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 fibrovascular ingrowth
(FVIG) at the sclerotomy sites, anterior hyaloidal proliferation,
neovascularisation of residual fibrovascular 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 reflecting 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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