Author:
Robyn R.Essendrop
Carl G.Skinner
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
- Blunt or penetrating trauma
- Retinal break/tear/detachment
- Any proliferative retinopathy
- Diabetes mellitus
- Sickle cell disease
- Retinal vein occlusion
- Eales disease
- Age-related macular degeneration
- Retinal angiomatosis
- Retinal telangiectasia
- Peripheral uveitis
- Subarachnoid or subdural hemorrhage:
- Intraocular tumor
Pediatric Considerations |
- Retinopathy of prematurity
- Congenital retinoschisis
- Pars planitis
- Child abuse:
|
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
Diagnostic 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 (RD) or intraocular tumor
- Echogenic dots, linear areas, or swirls in posterior chamber
- Variable echogenicity depending on acuity
- Fluorescein angiography to look for the cause
- CT scan/anteroposterior/lateral orbital films to rule out intraocular foreign body if suspected
Diagnostic Procedures/Surgery
If nontraumatic, scleral depression with indirect ophthalmoscopy to enhance retinal exam
Differential Diagnosis
- Vitreitis (leukocytes in the vitreous):
- RD without hemorrhage
- Central retinal venous occlusion (CRVO)
- Central retinal artery occlusion (CRAO)
Prehospital
- Protect the eye from trauma or pressure
- Monitor BP
Initial Stabilization/Therapy
- Bed rest with head of bed elevated
- No activity resembling Valsalva maneuver (lifting, stooping, straining, 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 RDs
- Surgical vitrectomy is needed for:
- Blood that does not clear with time
- VH from RD
- Associated neovascularization
- Hemolytic or ghost-cell glaucoma
Disposition
Admission Criteria
Retinal break or detachment
Discharge Criteria
Retinal break or detachment must be excluded as cause of hemorrhage
Follow-up Recommendations
Re-evaluation daily for 2-3 d; if etiology is still unknown, B-scan US every 1-3 wk to monitor for RD
- BagheriN, WajdaB, CalvoC, et al. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 7th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2016.
- DahlAA. Vitreous hemorrhage in emergency medicine . Medscape. 2013.
- GardinerMF. Overview of eye injuries in the emergency department . UpToDate. 2017.
- TalanyG, GuoM, EtminanM. Risk of intraocular hemorrhage with new oral anticoagulants . Eye. 2017;31:(4):628-631.
- TripathyK, ShahVA. Echography (Ultrasound). American Academy of Ophthalmology. 2017. Available at http://EyeWiki.aao.org.
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