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Vitreous Haemorrhage (VH)

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.

The prevalence of VH is about 7/100 000/year and the average age of patients is about 60 years.
The most common causes
- Vitreous detachment Vitreous Detachment, sometimes (in about half of the cases) with tears of the retina
- Proliferative diabetic retinopathy Diabetic Retinopathy
- Other diseases causing occlusions in the retinal vessels and associated with neovascularization
  - Retinal vein occlusion, more rarely arterial occlusion; vasculitis, sickle cell anaemia
- Retinal arterial macroaneurysms
- Exudative type of age-related macular degeneration Age-Related Macular Degeneration (AMD)
- A vascular anomaly of the retina
  - Coats' retinitis http://www.orpha.net/consor/cgi-bin/Disease_Search.php?lng=EN&data_id=1645, retinal angioma, von Hippel-Lindau disease http://www.orpha.net/consor/cgi-bin/Disease_Search.php?lng=EN&data_id=99
- Malignant choroidal melanoma
- Subarachnoid haemorrhage (SAH) Intracranial Aneurysm and Subarachnoid Haemorrhage (SAH)
- Sharp or blunt ocular trauma Ocular Injuries.

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.

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.

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.

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.