Vitreous Haemorrhage
Vitreous haemorrhage refers to bleeding into the vitreous humour, the clear, gel-like substance that fills the space between the lens and the retina at the back of the eye. The vitreous humour is normally transparent, allowing light to pass through unobstructed to the retina.
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Dr. Bhaskar Gupta
Consultant Ophthalmologist & Vitreo-Retinal Specialist
20+ years experience
Description
Vitreous haemorrhage refers to bleeding into the vitreous humour, the clear, gel-like substance that fills the space between the lens and the retina at the back of the eye. The vitreous humour is normally transparent, allowing light to pass through unobstructed to the retina. When blood enters this space, it obstructs the light pathway, leading to a sudden decrease in vision. The severity of vision loss depends on the amount of blood in the vitreous – a small bleed might cause floaters, while a large haemorrhage can lead to almost complete loss of vision. The blood often settles at the bottom of the vitreous cavity due to gravity, but movement of the eye can stir it up, causing fluctuating vision. It is a serious condition that requires prompt medical attention to identify and treat the underlying cause and prevent further complications or permanent vision loss.
Causes
Why it happens ?
- Proliferative Diabetic Retinopathy (PDR): This is the most common cause. In PDR, abnormal new blood vessels (neovascularization) grow on the surface of the retina or optic nerve in response to retinal ischemia (lack of oxygen). These new vessels are fragile and prone to rupture, especially when the vitreous gel pulls on them as it shrinks and separates from the retina.
- Posterior Vitreous Detachment (PVD) with Retinal Tear: As people age, the vitreous gel naturally shrinks and detaches from the retina (PVD). Sometimes, this detachment can pull on a weak area of the retina, causing a retinal tear or break. If a blood vessel is present at the site of the tear, it can bleed into the vitreous. A retinal tear with associated vitreous haemorrhage is a significant risk factor for retinal detachment.
- Ocular Trauma: A direct blow to the eye, penetrating injuries, or concussive forces can cause retinal blood vessels to rupture or lead to retinal tears and subsequent bleeding.
- Retinal Vein Occlusion (RVO): Blockage of a retinal vein can lead to a build-up of pressure, causing blood vessels to leak fluid and blood. If new, fragile blood vessels form (neovascularization), they can bleed into the vitreous.
- Retinal Macroaneurysm Rupture: A retinal macroaneurysm is an outpouching of an artery in the retina, typically occurring in older individuals with high blood pressure. If it ruptures, it can cause significant intraretinal or vitreous haemorrhage.
- Terson’s Syndrome: This refers to vitreous haemorrhage associated with an acute increase in intracranial pressure, typically from a subarachnoid haemorrhage. The sudden increase in pressure can cause retinal and vitreous bleeding.
Incidence
Vitreous haemorrhage is not a standalone disease but a symptom of an underlying condition. Its incidence varies depending on the prevalence of its causative factors. The most common cause, especially in developed countries, is proliferative diabetic retinopathy, which accounts for approximately 30-50% of all cases. Other significant causes include posterior vitreous detachment (PVD) with retinal tear (15-20%), ocular trauma (12-18%), and retinal vein occlusion (4-16%). Less common causes include macroaneurysms, subarachnoid haemorrhage (Terson’s syndrome), and sickle cell retinopathy. The overall incidence is difficult to precisely quantify globally but is significant given the prevalence of diabetes and other retinal conditions. It can occur at any age, though it is more common in older adults due to age-related changes in the vitreous and retina.
Symptoms
The symptoms of vitreous haemorrhage can vary widely depending on the amount and location of the blood. They usually appear suddenly and are often unilateral (affecting one eye). Common symptoms include:
Sudden onset of floaters
These can appear as cobwebs, spots, or strands drifting across the field of vision. They are often described as "smoke rings" or "spider webs."
Blurred vision
Vision can range from mildly hazy to severely obscured, depending on the density of the blood.
Fluctuating vision
Vision may be worse in the morning (as blood settles with gravity during sleep) and improve slightly during the day, or vice versa with eye movements.
Reddish tint to vision
In some cases, patients may perceive a reddish or brown haze.
Shadows or dark spots in the vision
These can appear as fixed defects in the visual field.
Sudden, painless loss of vision
This is characteristic of a larger haemorrhage, where vision can drop to hand movements or light perception only.
Treatment Options
The treatment for vitreous haemorrhage depends on the underlying cause, the amount of blood, and the patient’s visual acuity.
Observation
In many cases, especially with smaller bleeds, the blood will clear on its own over several weeks or months. Patients are often advised to rest with their head elevated, which can help the blood settle inferiorly, improving vision temporarily. Regular monitoring by an ophthalmologist is essential during this period to ensure the blood is clearing and to check for underlying retinal issues.
Vitrectomy
This surgical procedure is performed if the blood does not clear on its own within a reasonable timeframe (typically 2-3 months), if vision is severely compromised, or if there is an underlying condition requiring immediate surgical intervention (e.g., retinal detachment, persistent traction from proliferative diabetic retinopathy). During vitrectomy, the surgeon removes the blood-filled vitreous gel and replaces it with a clear saline solution, gas, or silicone oil. This allows for direct visualization and treatment of the underlying retinal pathology.
Laser Photocoagulation
If the underlying cause is proliferative diabetic retinopathy, laser photocoagulation (panretinal photocoagulation or PRP) may be performed after the vitreous haemorrhage has cleared, or during vitrectomy, to ablate the abnormal blood vessels and prevent further bleeding.
Anti-VEGF Injections
In some cases, particularly those related to proliferative diabetic retinopathy, anti-VEGF injections may be used to help regress the abnormal new blood vessels and reduce the risk of further bleeding, either as an adjunct to observation or prior to surgery.
Treating the Underlying Cause
Crucially, managing the underlying condition (e.g., strict blood sugar and blood pressure control for diabetes, treatment of retinal tears) is paramount to preventing recurrence and preserving long-term vision.