DESCRIPTION 
Vitreous hemorrhage is a secondary diagnosis; identification of a specific cause is necessary for successful treatment:
- Retinal vessel tear due to vitreous separation
- Sudden tearing of vessels due to trauma
- Spontaneous bleeding due to neovascularization (e.g., diabetics)
ETIOLOGY
Pediatric Considerations
[Outline]
SIGNS AND SYMPTOMS
- Sudden, painless unilateral loss or decrease in vision
- Appearance of dark spots (floaters), cobwebs, or haze in visual axis:
- Above findings sometimes accompanied by flashing lights; floaters move with head movements
- Blurred vision, decreased visual acuity
- Loss of red reflex
- Inability to visualize fundus
- Mild afferent papillary defect
History
- Ocular or systemic diseases
- Trauma
Physical Exam
Fundoscopic exam:
- Absent red reflex
- No view of the fundus
- Acute:
- RBCs in anterior vitreous
- Chronic:
- Yellow appearance from hemoglobin breakdown
ESSENTIAL WORKUP
- History with special attention to pre-existing systemic disease and trauma
- Complete ocular exam including:
- Slit lamp
- Tonometry
- Dilated fundoscopic exam
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC
- PT/PTT/INR if indicated
- Electrolytes, BUN, creatinine, glucose
Imaging
- B-scan US when no direct retinal view is possible to rule out retinal detachment or intraocular tumor
- Fluorescein angiography to define the cause
- CT scan/anteroposterior/lateral orbital films to rule out intraocular foreign body
Diagnostic Procedures/Surgery
If nontraumatic, scleral depression
DIFFERENTIAL DIAGNOSIS
- Vitreitis (leukocytes in the vitreous):
- Retinal detachment without hemorrhage
- Central retinal venous occlusion (CRVO)
- Central retinal artery occlusion (CRVA)
[Outline]
PRE-HOSPITAL
Protect the eye from trauma or pressure:
INITIAL STABILIZATION/THERAPY
- Bed rest with head of bed elevated
- No activity resembling Valsalva maneuver (lifting, stooping, or heavy exertion)
- Avoid NSAIDs and other anticlotting agents.
ED TREATMENT/PROCEDURES
- Urgent ophthalmologic consultation within 24–48 hr is needed with treatment based on the cause of the hemorrhage; an exam is carried out by the consultant:
- Laser photocoagulation or cryotherapy for proliferative retinal vascular diseases
- Repair of retinal detachments
- Surgical vitrectomy is needed for:
- Blood that does not clear with time
- VH from retinal detachement
- Associated neovascularization
- Hemolytic or ghost-cell glaucoma
[Outline]
DISPOSITION
Admission Criteria
Retinal break or detachment
Discharge Criteria
Retinal break or retinal detachment must be excluded as cause of hemorrhage.
FOLLOW-UP RECOMMENDATIONS
Re-evaluation daily for 2–3 days; if etiology is still unknown, B-scan US every 1–3 wk.
[Outline]
- Dahl AA. Vitreous Hemorrhage in Emergency Medicine. Medscape Reference. February 2013.
- Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
- Hollands H, Johnson D, Brox AC, et al. Acute-onset floaters and flashes: Is this patient at risk for retinal detachment? JAMA. 2009;302(20):2243–2249.
- Leveque T. Approach to the patient with acute visual loss. In: DS Basow, ed. UpToDate. Waltham, MA: UpToDate; 2013.
- Lorente-Ramos RM, Armàn JA, Muñoz-Hernàndez A, et al. US of the eye made easy: A comprehensive how-to review with ophthalmoscopic correlation. Radiographics. 2012;32(5):E175–E200.
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