What is vitreous hemorrhage?
The vitreous body is located in the center of the eyeball, between the lens and the retina, and appears as a “gel”. The vitreous gel occupies about 2/3 of the total volume of the eye and is a transparent semi-solid or liquid substance that fills the space between the lens in front of the eye and the retina covering the back of the eye. A healthy vitreous is completely transparent allowing light to reach the retina without any problems, thus obtaining a clear vision.
Normally, there are no blood vessels in the vitreous gel. Abnormal blood vessels can grow in the vitreous gel in a variety of eye diseases, most commonly in diabetic retinopathy. Of course, there are many blood vessels surrounding the vitreous gel. A vitreous hemorrhage occurs when a blood vessel ruptures and bleeds into or near the vitreous cavity. Vitreous hemorrhage is the penetration of blood into this “gel”, usually due to a blockage or damage to the blood vessels on the retina.
A vitreous hemorrhage can result from proliferative retinopathy, a condition in which new and abnormal blood vessels grow on the surface of the retina. This is called neovascularization. When left untreated, these new blood vessels can continue to grow and spread through the vitreous to the pupil area. This can increase ocular pressure (pressure in the eye) which presses on the optic nerve. Damage to the optic nerve is irreparable and can lead to vision loss. Bleeding from a vitreous hemorrhage can also cause scar tissue to form near the back of the eye. This can remove the retina from the back lining of the eye, requiring further treatment to prevent the retina from detaching and permanently impairing the vision.
What symptoms do you experience in case of vitreous hemorrhage?
The initial symptoms of vitreous hemorrhage are floating particles and blurred vision. The floating particles we associate with bleeding, patients describe as lines, cobwebs or many dark spots. If the vitreous hemorrhage is very significant, there could be a major loss of vision. Whenever you experience a sudden appearance of floating particles or vision loss, a quick and careful examination of the retina is necessary both to make a diagnosis and to find the underlying cause of the vitreous hemorrhage and determine if you need specific therapy.
One of the reasons ophthalmologists are very concerned about raising awareness of this condition is that a vitreous hemorrhage is not painful. In many cases, a vitreous hemorrhage can develop very quickly and without pain that would indicate a medical emergency.
What are the risk factors for vitreous hemorrhage?
The most common cause of vitreous hemorrhage is severe diabetic eye disease, which is mainly seen in older people. The other common causes of vitreous hemorrhage also tend to occur in adults over the age of 50, with the exception of ocular trauma, which can occur at any age.
There are many possible causes of IVH, including systemic diseases such as:
- Diabetes mellitus
- Sickle cell anemia (sickle cell disease)
Also, as we age, the vitreous gel liquefies and separates from the retina, creating a posterior vitreous detachment. Bleeding can sometimes be associated when this occurs. Other causes of vitreous hemorrhage include ocular trauma, retinal breaks or detachments, diabetic retinopathy, retinal vein occlusion, other vascular abnormalities, tumors, and wet macular degeneration.
How can vitreous hemorrhage be prevented?
Preventing IVH is done by preventing the causes that lead to the condition. This includes careful and regular management of diabetic eye disease (which tends to be worse in uncontrolled diabetes) and high blood pressure, and quit smoking.
The eye should always be protected during activities with high risk of trauma, such as carpentry, mechanics, use of firearms, and sports using a ball (tennis, football, etc.).
What types of vitreous hemorrhage are there?
There are three main categories of causes of vitreous hemorrhage:
Development of abnormal blood vessels
Some ocular disorders can cause the development of abnormal blood vessels that bleed into the vitreous body. This is the case in advanced stages of diabetic retinopathy, occlusion of certain retinal veins, or neo-vessel formation in some cases of macular degeneration. In this case, the newly formed and fragile blood vessels will create a hemorrhage in the vitreous.
Rupture of normal blood vessels
Retinal blood vessels that are damaged due to trauma or injury can cause intravitreal hemorrhage. Other ocular problems can also damage retinal blood vessels, such as retinal rupture. Another cause is occlusion of a retinal vein. In this case, the veins feeding the retina are blocked, leading to hemorrhage into the vitreous “gel”. A rare cause of intravitreal hemorrhage is Terson’s syndrome, which causes bleeding known as subarachnoid bleeding. Hypertension or Eales disease are among other known causes.
Bleeding from an adjacent source
Occasionally, blood from another source can cause vitreous hemorrhage. Although very rare, a hemorrhage elsewhere in the eye, or even a tumor, can cause blood to leak into the vitreous body.
What treatment methods exist for vitreous hemorrhage?
Treatment for vitreous hemorrhage depends on the cause and severity of the bleeding. The treatment steps start with finding the source of the bleeding and stopping it.
Once the source of the bleeding has been identified, treatment will depend on the cause. If there is not much blood in the vitreous and the source of the bleeding can be seen, laser treatment can be applied to the bleeding vessels and then surgery can be performed to repair any potential breaks in the retina. After this stage, it may take some time for the blood to reabsorb. This may take several weeks. You will be advised to avoid intense activity for at least a few days as this could dislodge clots and trigger new bleeding. You are also advised to sleep with the head of the bed elevated, as this allows the blood in the vitreous to settle at the bottom of the eye, out of the line of sight.
If the blood in the vitreous obstructs the vision and prevents treatment of the bleeding, then the entire vitreous can be removed first. This procedure is called a vitrectomy. Doctors will perform a vitrectomy if they can’t see the back of the eye or if vision is not good enough to treat bleeding there safely.
Specific treatments
Laser photocoagulation is the common treatment for fragile abnormal vessels. Treating them stops bleeding and prevents further bleeding. Laser photocoagulation is also used to repair retinal damage, including retinal detachments.
Anti-VEGF injections aim to shrink abnormal new vessels that have formed in the eye. They are sometimes used in patients with diabetes, in addition to other treatments such as laser photocoagulation and vitrectomy, to reduce bleeding.
Vitrectomy is the complete removal of the vitreous along with the membrane surrounding it. This is done when there is so much blood in the vitreous that it is impossible to diagnose and treat the cause. Vitrectomy is also used if the blood in the vitreous clears very slowly and vision remains impaired.
Temporary monitoring is usually the option chosen once the bleeding has stopped. Most cases of vitreous hemorrhage do not require vitrectomy. The blood slowly clears from the vitreous, allowing light to pass through it again. If the basic vision is not damaged, then normal vision will be restored.
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