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Disease Entity

Vitreous Hemorrhage ICD-9 379.23

Disease

Vitreous Hemorrhage is a common cause of acute vision loss having an incidence of approximately 7 cases per 100,000. It is therefore frequently encountered on an emergent basis by ophthalmologists and Emergency Room professionals alike. Although the diagnosis is often straightforward to make on fundoscopic examination or ultrasonography, the underlying etiology may require further investigation to determine.

Etiology

The etiology of vitreous hemorrhage and their frequencies are variable according to the characteristics of the study population. The three most common causes include proliferative diabetic retinopathy, vitreous detachment with or without retinal tear, and ocular trauma which account for 59-88.5% of all cases. Less common causes of vitreous hemorrhage include retinal vein occlusion, proliferative sickle cell retinopathy, retinal macroanuerysm, subarachnoid hemorrhage (Terson's syndrome), and age-related macular degeneration.

Risk Factors

The population at risk for vitreous hemorrhage will have the demographic and clinical characteristics according to its common causes. Poorly controlled diabetics with end-organ damage such as proliferative diabetic retinopathy are at high risk. People younger than 40 with vitreous hemorrhage often have a history of recent ocular trauma whereas older, non-diabetic populations with vitreous hemorrhage likely suffered an acute, posterior vitreous detachment and/or retinal tear.

There have been reports of vitreous hemorrhage in patients treated with anticoagulation and antiplatelet agents, but these cases are rare and often in patients with significant preexisting retinal pathology (e.g. neovascular age-related degeneration). Systemic coagulation disorders and blood dyscrasia such as leukemia and thrombocytopenia has reportedly increased the risk of vitreous hemorrhage, but these cases are also rare.

General Pathology

Extravasation of blood into and around the vitreous cavity is generally cased by three basic mechanisms. Abnormal blood vessels prone to bleeding grow in response to ischemic conditions such as diabetic retinopathy and retinal vein occlusion. The elaboration of angiogenic factors suh as vasucalr endotheilial growth factor (VEGF), basic fibroblast growth factor, and insulinlike growth factor potentiate nevascularization and have recently become popular pharmacotherapeutic targets.

The second mechanism involves the rupture of normal vesslels through mechanical force. This can occur from ocular trauma (both blunt or perforating) and in association with posterior vitreous detachment (PVD). Vitreous Hemorrhage in the setting of acute PVD is associated with a retinal tear or break in 70-95% of cases and should invoke consideration of a retinal specialist referral.

Extension of hemorrhage from a source adjacent to the vitrous is the third mechanism. Retinal macroaneursms, tumors, or choroidal neovascularations secondary to conditions such as age-related macular degeneration can cause "break-through" bleeding into the vitreous.

Pathophysiology

Hemorrhage into the vitreous body results in rapid clot formation and clears at a rate of approximately 1% per day. Erythrocytes exit through the trabecular meshwork, undergo hemolysis, phagocytosis, or persist within the vitreous for many months. The cellular response to erythrocytes in the vitreous is unusual because there is no early polymorphonuclear cell response and the ensuing inflammatory response is instead more similar to a "low-turnover" granuloma. The muted inflammatory response in the immunologically privileged eye serves to mitigate ocular tissue damage and promote clarity of the visual axis.

Primary prevention

Primary prevention should be directed at controlling risk factors for systemic vascular disease such as diabetes, hypertension, and smoking. Frequent dilated fundus exams can reveal advanced retinopathy in high risk populations and provide the opportunity for therapeutic intervention.

Diagnosis

Evidence of vitreous hemorrhage is often seen on physical exam and inferred through history. Systemic past medical and ocular history can help lead to diagnosis.

History

Sudden, painless visual loss or haze is a common presentation. Patients may describe new onset floaters, shadows, or cobwebs. History of diabetes, hypertension, sickle cell disease, trauma, previous retinal conditions or ocular surgery may help lead to the diagnosis

Physical examination

Visual acuity is variable based on the location, size, and diffuseness of vitreous hemorrhage with respect to the macula. In severe cases, patients may have dramatically reduced visual acuity and/or visual field defects. Slit lamp examination usually reveals red blood cells in the anterior vitreous. Presence of iris rubeosis and intraocular pressure should be noted. Gonioscopy should be used to detect neovascularization of the angle. Dilated fundus exam may reveal frank blood in the vitreous or an obsured view suggesting diffuse hemorrhage. If associated with acute posterior vitreous detachment, retinal tear or detachment should be ruled out using scleral depression. It is important to thoroughly examen the fellow eye, as it will often reveal clues as to the etiology.

Signs

See Physical Exam

Symptoms

See History

Clinical diagnosis

The presence of ophthalmascopically visible vitreous hemorrhage with evidence of intraocular neovascularization in the affected or unaffected eye is suggestive of ischemia secondary to retinovascular disease such as diabetes, vascular occlusion, or sickle cell retinopathy. Hemorrhage associated with acute posterior vitreous detachment is suggestive of retinal tear/detachment or vessel avulsion.

Diagnostic procedures

In the absence of a view to the retina B-scan ultrasonography can detect vitreous hemorrhage, retinal detachment or tears, intraocular tumors or foreign bodies. Flourescein angiography

Laboratory test

Laboratory testing is used according to clinical suspicion to uncover new onset diabetes or more occult conditions such as sickle cell disease, leukemia, thrombocytopenia, and other coagulopathies

Differential diagnosis

Proliferative Diabetic Retinopathy Posterior vitreous detachment with or without Retinal tear Retinal tear (with or without detachment) Retinal vein or artery occlusion Hypertensive retinopathy Avulsed retinal vessel Macroaneurysm Choroidal neovasculariation (secondary to Age-related macular degeneration, Presumed ocular histoplasmosis Syndrome, etc.) Terson syndrome Radiation retinopathy Inflmmatory conidtions (Behcet's, retinal vasculitis, Eales disease, Systemic lupus erythematosis, etc.) Leukemia Tumors (Melanoma, Retinoblastoma, Vasoproliferative, etc.) Retinopathy of Prematurity Blood disorders (thrombocytopenia, leukemia, hemaglobinopathies, etc.) Trauma (blunt, Shaken baby syndrome, etc.)

Management

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General treatment

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Medical therapy

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Medical follow up

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Surgery

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Surgical follow up

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Complications

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Prognosis

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Additional Resources

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References

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