Vitreous Hemorrhage: Causes, Symptoms & Treatment

What Is a Vitreous Hemorrhage?

The vitreous humor is a clear, gel-like substance that fills the interior of the eyeball and helps maintain its shape. A vitreous hemorrhage (also known as hemophthalmus) occurs when blood from damaged or abnormal blood vessels leaks into this vitreous space. Because the vitreous is normally completely transparent, even a small amount of blood can significantly impair vision.

Causes

A vitreous hemorrhage can result from a variety of diseases or injuries. The most common causes include:

• Diabetic retinopathy: Long-standing diabetes can lead to the growth of fragile new blood vessels in the retina that are prone to bleeding.
• Retinal tear or retinal detachment: Tears in the retina can damage blood vessels and cause bleeding into the vitreous.
• Posterior vitreous detachment: As the vitreous separates from the retina with age, it can rupture small blood vessels.
• Eye trauma: Blunt or penetrating injuries to the eye can directly cause bleeding.
• Other causes: Retinal vascular occlusions, age-related macular degeneration, ocular tumors, or blood clotting disorders.

Symptoms

Symptoms of a vitreous hemorrhage can vary widely depending on the severity of the bleed. Typical signs include:

• Sudden appearance of floaters, cobwebs, or dark spots in the visual field
• Blurred or hazy vision
• A reddish or dark veil over the visual field
• In severe cases, complete or near-complete vision loss in the affected eye
• Flashes of light, particularly at the onset of bleeding

Pain is not typically associated with an uncomplicated vitreous hemorrhage. However, the sudden onset of these symptoms requires immediate evaluation by an ophthalmologist.

Diagnosis

Diagnosis is made through a comprehensive ophthalmological examination. The following methods are commonly used:

• Slit-lamp examination: Allows direct assessment of the anterior segment and the vitreous body.
• Ophthalmoscopy (fundoscopy): Used to examine the retina and identify the source of bleeding.
• Ocular ultrasound (B-scan): Particularly important when the retina cannot be visualized directly due to the hemorrhage, for example to rule out retinal detachment.
• Fluorescein angiography: An imaging technique that highlights the retinal blood vessels and can identify abnormal vascularization.

Treatment

Treatment depends on the underlying cause, the severity of the hemorrhage, and the overall condition of the patient.

Conservative Management

In mild cases, a watch-and-wait approach may be appropriate, as blood in the vitreous often clears on its own over time. Bed rest with the head slightly elevated can help the blood settle and temporarily improve vision.

Laser Photocoagulation

If the underlying cause is diabetic retinopathy or a retinal tear, laser treatment can be applied to the retina to seal off abnormal vessels and prevent further bleeding.

Intravitreal Injections (IVOM)

For conditions such as diabetic retinopathy or wet age-related macular degeneration, anti-VEGF medications can be injected directly into the vitreous. These drugs inhibit the growth of abnormal blood vessels.

Vitrectomy

For severe or persistent vitreous hemorrhages that do not clear spontaneously, surgical removal of the vitreous (vitrectomy) may be necessary. During this procedure, the blood-filled vitreous is replaced with a clear saline solution or gas.

Prognosis

The prognosis of a vitreous hemorrhage depends largely on the underlying cause and how quickly treatment is initiated. Mild hemorrhages often resolve within weeks to months. In severe cases or when the underlying condition is left untreated, permanent vision damage may occur. Early ophthalmological care is therefore essential.

References

1. Lang, G. K. (Ed.): Ophthalmology - A Short Textbook, 2nd Edition, Thieme Publishers, Stuttgart, 2000.
2. Feltgen, N. & Walter, P.: Rhegmatogenous Retinal Detachment - an Ophthalmologic Emergency. Deutsches Ärzteblatt International, 111(1-2), 12-22, 2014. PubMed PMID: 24565273.
3. American Academy of Ophthalmology: Vitreous Hemorrhage - Preferred Practice Pattern, AAO, 2023. Available at: https://www.aao.org