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Vitreous Hemorrhage

I remember the summer day when Neelam came to me for an eye check-up. She was in a panic mode and was blaming her husband for her miserable condition. She needed his support to walk as she was unable to see clearly. I calmed her down and examined her eye. She had a vitreous hemorrhage in one eye and the other eye had lost vision due an eye injury in childhood. So, she was managing herself with one eye all these years. Now because of the bleeding inside the cavity of her eye she suddenly lost her vision. She was a known diabetic and inspite of her physician’s repeated warnings she didn’t get her eye check-up done. She last checked her eyes 10 years back when everything was declared to be normal. Diabetic retinopathy (DR) is a known complication in long standing diabetics. Regular eye check-ups to detect and control DR is therefore very important. I reassured Neelam and advised her bed rest with head-up position. She gradually resumed part of her vision. We treated her with lasers and injections and her condition improved. Now she comes for regular follow-ups.  Lets have a closer look at vitreous hemorrhage and its various causes.

Vitreous hemorrhage is bleeding within cavity of the eyeball. Cavity of eyeball is filled with transparent jelly like structure called Vitreous. This vitreous allows light to pass through cavity of eyeball and fall on Retina where image forms. Most of this humor consists of water, as well as a lower amount of collagen, salt, and sugar. Very high content of water keeps it transparent. So Vitreous hemorrhage is condition where vision gets affected due to bleeding in this transparent jelly. Vision affection may vary from slight blurring of vision to complete loss of vision depending on the amount of bleeding.

The most common causes of vitreous hemorrhage are-

  1. Proliferative diabetic retinopathy
  2. Retinal vascular occlusions
  3. Retinal tear
  4. Trauma


Vitreous hemorrhage can also occur in Wet macular degeneration, Retinal artery macro aneurysm, secondary to subarachnoid hemorrhage (Terson’s syndrome) and various vasculopathies causing neovascularisation. Other rare cases includes blood dyscrasias, Valsalva retinopathy and intraocular tumors.

Symptoms Associated

1) Sudden appearance of floaters - small vitreous hemorrhage

2) Sudden painless loss of vision- large vitreous hemorrhage


Fate of vitreous hemorrhage

  • Many cases of Vitreous hemorrhage will have Complete resolution of bleeding, which may occur within 4-6 weeks. This is because of tendency of intraocular structures (Trabecular meshwork) to absorb it.  This will only happen if primary bleeding  stopped and recurrent bleeding is not happening.
  • Cases where bleeding keeps on happening, spontaneous resolution will not happen and vision remains grossly reduced. If such bleeding is left for long duration then there are chances of complications because of prolonged Vitreous hemorrhage


Complications
Vitreous liquefaction/Degeneration: if Vitreous hemorrhage is left alone it undergoes spontaneous resolution in almost 60% cases, which is best outcome without any intervention. But this is associated with liquification of vitreous jelly.
Ghost cell glaucoma: While undergoing spontaneous resolution, bleeding breaks into fine components which clogs the drainage system of eye leading to increase in intraocular pressure called Ghost cell Glaucoma.
Tractional retinal detachment:  If vitreous hemorrhage is dense and left alone, resolution is also associated with surface contraction in vitreous and retina. This leads to tractional retinal detachment.

Investigations
B scan: Is the investigation of choice if vitreous hemorrhage is quite dense and the retina eye doctor is unable to assess the retina. B-scan shows Retina status, Giant retinal tears and status of vitreous jelly.

(B scan image in patient with vitreous hemorrhage)
FFA : Retinal angiography is useful in cases of Proliferative Diabetic Retinopathy and all other vascular causes of hemorrhage once the vitreous hemorrhage settles down and allow some retinal visibility.

Treatment

  1. Wait and watch : All fresh cases of vitreous hemorrhage can be watched with frequent evaluation provided Retina is attached beneath hemorrhage and there is no peripheral retinal tear as cause of hemorrhage. Second thing to be kept in mind is Intraocular Pressure (IOP), if IOP is under control then hemorrhage can be watched as almost 60% cases will have spontaneous resolution.
  2. Laser: Cases where Vitreous hemorrhage is due to Retinal tear, Diabetic Retinopathy, Retinal Vasculitis or Retinal vascular occlusion, needs to be treated with Argon laser for faster resolution.
  3. Surgery: Surgery is indicated in case where underlying retina is detached or having a traction, if IOP is increased and not medically controlled or if its recurrent with no resolution even after an observation of 6 weeks. Surgery involves clearing of Vitreous hemorrhage followed by treatment of underlying pathology.


About Dr. Yogesh Patil:
Dr. Yogesh Patil (MBBS, MS (Ophth), Fellow Vitreo-Retinal Surgery) is a Vitreo- Retinal Surgeon at Advanced Eye Hospital and Institute. He has achieved remarkable competence in the treatment of various diseases involving the retina, vitreous and macula as well as in performing various Vitreo-retinal surgeries.

About Advanced Eye Hospital and Institute:
Advanced Eye Hospital and Institute in Navi Mumbai is one of the best eye hospitals in Mumbai.  Eye check-up rooms and the operation theatres are state-of-art and equipped with the best diagnostic and surgery machines. Personalised care, infection free modular operation theatres and beautiful ambience compliment the cutting-edge eye care offered at AEHI. Besides treating patients from Kharghar, Nerul, Vashi and Panvel, patients from all over western India travel to AEHI for world class eye care management.