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Vitreous Haemorrhage (VH)

Essentials

  • The visual field is suddenly and without pain blurred by a fog or haze that moves when the head/eye is moved.
  • If the patient has no known underlying disease predisposing to VH (e.g. earlier treatment for proliferative diabetic retinopathy), he/she should be referred to an ophthalmologist immediately, or the next day at the latest, in order to identify the cause of the bleeding.

Epidemiology and aetiology

Symptoms and findings

  • A fog or haze suddenly appears in the visual field. There is no pain involved. The haze moves when the head/eye is moved.
    • Vitreous opacities associated with e.g. inflammation appear more slowly.
    • In the early stage, floaters resembling soot specks as well as flashes of light may appear.
    • The more dense blood clots may be seen as separate swaying shadows in the visual field (typical to vitreous haemorrhage).
  • The impairment of vision depends on the amount of bleeding.
    • Profuse vitreous haemorrhage may impair the vision down to light perception.
  • The eye looks unaffected on outward inspection.
  • On ophthalmoscopy, moving dark shadows are seen in the red reflex.
  • View to the fundus may be cloudy or the details might not be seen at all. In this case, also the red reflex is gone.

Referral

  • If the patient has no known underlying disease predisposing to VH, he/she should be examined by an ophthalmologist, urgently, or the next day at the latest, in order to identify the cause of the bleeding.
    • In case of trauma, immediate emergency referral to an ophthalmologist is required regardless of the hour if there is a suspicion of open penetrating ocular injury.
    • Ultrasonography is important in detecting retinal detachment if the fundus is not visible.
  • If the underlying cause is e.g. diabetes and the fundi have been laser-treated because of diabetic retinopathy, referral for treatment in 1-7 days is sufficient. Alternatively, the patient is advised to contact his/her own ophthalmologist for the arrangement of further investigations and treatment and an earlier follow-up visit, provided that the eye is otherwise symptomless. If the patient has not received laser therapy in the fundus of the eye, an emergency referral is made.

Treatment

  • Determined by the specialist examination
  • Most VHs clear up spontaneously: small ones in a few days, profuse ones within weeks or months.
    • Tranexamic acid should not be given.
    • The patient can be instructed to sleep using a higher pillow than usual or in a sitting position.
      • Descent of the blood away from the area of sharp vision (fovea) speeds the recovery of vision.
  • Laser treatment is given in proliferative retinopathy and to seal retinal breaks caused by posterior vitreous detachment or trauma.
  • Vitrectomy is indicated if the vitreous humour does not clear up, as is always a prompt intervention for reattachment of the retina in case of retinal detachment.

    References

    • Weng CY, Starr M, eds. Vitreous Hemorrhage. American Academy of Ophthalmology, EyeWiki. December, 2022. Accessed February 9, 2023. http://eyewiki.aao.org/Vitreous_Hemorrhage
    • Diabetic retinopathy. Current Care Guideline. Working group appointed by Finnish Medical Society Duodecim, Ophthalmological Society of Finland and Medical Advisory Board of the Finnish Diabetes Association. Helsinki: Finnish Medical Society Duodecim 2014 (accessed 9 Feb 2023). English summary available at: http://www.kaypahoito.fi/en/ccs00019.