Approach to a case of vitreous haemorrhage

Sandeep Saxena MS, FRCSEdProfessor

Department of OphthalmologyKGMU, Lucknow

September 27, 2014

Vitreous Humor• Inert , transparent, jelly-like structure • Normal volume- 4ml• Composed of a network of collagen fibrils

interspersed with hyaluronic acid molecules• Can be divided into cortex and nucleus• Attachments - Vitreous base-strongest adherance about

4mm across the orra serrata -Around margins of optic disc, foveal region,

along retinal vessels

• Ageing changes- -Dissociation of hyaluronate from collagen

fibrils -Pooling of hyaluronate -Fibril degeneration and decreased elasticity -Drainage of hyaluronate into retrovitreal

space (posterior vitreous detachment)

• Vitreous degeneration - Syneresis -Vitreous liquefaction, fibril aggregation

and condensation -Associated with floaters -Caused by myopia, senescence, trauma,

inflammation, etc.

- Posterior vitreous detachment

Vitreous Haemorrhage Causes• Proliferative retinopathies- -Diabetes mellitus -Retinal vein occlusion -Retinopathy of prematurity -Eale’s disease• Rhegmatogenous retinal detachment• Posterior vitreous detachment• Trauma• Systemic – Bleeding disorders

Pathophysiology• Retinal ischemia causing release of angiogenic

vasoactive factors (like VEGF)

• Tear in retinal vasculature due to break in the retina or detachment of posterior vitreous

• Subretinal bleeding with secondary extension into the vitreous cavity- less common

Clinical features• Symptoms- -Sudden appearance of floaters - small vitreous

haemorrhage -Sudden painless loss of vision- large vitreous

haemorrhage• Signs- - No red glow on distant direct ophthalmoscopy - Blood in vitreous cavity on indirect

ophthalmoscopy

Patient workup

• Slit lamp examination of the eye• Pupil dilatation and fundus examination• B scan ultrasound for posterior segment

evaluation • Blood tests to check for specific causes such as

diabetes• CT scan may be required in some cases to

check for injury around the eye

Fate of vitreous haemorrhage

• Complete resolution may occur within 4-8 weeks without organisation with vitreous

• Organisation of haemorrhage with formation of a yellowish-white debris occurs in persistent or recurrent bleeding

• Complications like vitreous liquefaction, degeneration and ghost cell glaucoma may occur

• Fibrous proliferation may develop which may be complicated by tractional retinal detachment

Management

• Conservative management consists of bed rest with elevation of patient’s head end to facilitate settlement of blood

• Treatment of cause- Once the blood settles down, indirect ophthalmoscopy should be done to locate and further manage the cause of haemorrhage

• Pars plana vitrectomy may be attempted to clear the vitreous, if the haemorrhage does not get absorbed in 3 months

• Early vitrectomy followed by laser photocoagulation may be required in cases associated with retinal detachment

Thank you