Vitreous hemorrhage

Pertinent questions when taking the history

• When did the vision decline begin?
• Have you noticed a red, grey, or darkening of your vision? It is often described as waves, haze, or floaters in the vision.
• Have you also experienced flashes of light? Flashes of light are less common in a vitreous hemorrhage.
• What is the pertinent systemic history? Ask about renal failure or end stage renal disease, uncontrolled diabetes, and elevated blood pressure.
• Has this ever happened in the past? Have you ever received laser treatment on your eyes in the past?
• Do you already see an ophthalmologist or retinal specialist for eye care?

Visual vital signs

Vision, pressure, and pupils, recorded and handed off like any other vital sign. In a vitreous hemorrhage the pressure is the one most likely to change management in the next hour.

Describe the focused anatomy

• The external exam will often look normal, with a white and quiet conjunctiva and an unaffected external eyelid examination.
• Look carefully for visible blood vessels on the iris, as this might suggest neovascularization that can often lead to hemorrhages and elevations in intraocular pressure which may need to be controlled. These vessels are often only visible with a slit lamp exam.
• Pupils should be dilated with tropicamide 1% and phenylephrine 2.5% when available.
• Using a direct ophthalmoscope or wide field ophthalmoscope, a clear view to the optic nerve and macula often excludes a vitreous hemorrhage.
• When a hemorrhage is present, the view may seem blurry, or the examiner may not be able to view any structures in the back of the eye compared to the unaffected eye.

Supporting imaging, if needed

• UltrasoundOften performed in the emergency setting to evaluate for vitreous and retinal pathology. It is very frequent that it does not lead to an accurate diagnosis of a retinal detachment, retinal tear, or vitreous hemorrhage, because these findings commonly look similar. Diagnosis should not rely on ultrasound alone. Clinical examination and patient history are often more definitive.
• CTSome enhancement can be seen inside the vitreous, but this finding is not diagnostic. CT is not recommended for a vitreous hemorrhage unless trauma or foreign body is suspected.

Treatment

• Call ophthalmologyDirect communication with ophthalmic follow up for the next day is standard of care for definitive diagnosis and treatment plan.
• If there is no retinal tear or detachmentTreatment is often supportive, allowing the blood to clear on its own over a period of days to weeks until laser therapy can be performed to reduce the recurrence of hemorrhage in the setting of retinal ischemia and neovascularization. Occasionally an intravitreal injection is necessary to reduce vascular aggression and recurrent hemorrhage.
• Blood thinnersConsideration should be given to discontinuing them if appropriate systemically, but this is not necessary in most cases.
• If the pressure is elevatedTreat with a pressure lowering medication such as brimonidine 0.2% twice daily or dorzolamide 2% twice daily to the affected eye. If the pressure is significantly elevated, additional agents may be necessary, including oral or intravenous, depending on the level of neovascularization.

Follow up

• IntervalNext one to two day outpatient follow up for definitive diagnosis and treatment plan with ophthalmology.
• What raises your confidence in the diagnosisThe patient reports red lines in their vision, or floaters in the absence of flashes of light or a shade in the vision. Patients with a vitreous hemorrhage often have a significant vascular history and may have a long history of uncontrolled diabetes, renal failure, or current dialysis treatment.