Vitreous Haemorrhage

What's going on?

Blood has been released into the vitreous cavity resulting in a reduction in vision. This reduction may be minimal in the form of black, stringy floaters or complete, where vision is suddenly reduced to hand motion or perception of light.

If I examine the patient, what will I find?

The anterior segment will be normal and there will be no RAPD. When you dilate the pupil, you not be able to see the fundus at all. Try fundoscopy in the other eye. If you can see the retina in the normal eye then your technique is sound and there is something blocking your view; i.e., a vitreous haemorrhage.

What if I've diagnosed it?

These patients should be referred with an urgency dependent upon the most likely underlying aetiology.

If the patient is myopic, then they may have had a retinal detachment or retinal tear that has resulted in a torn retinal blood vessel. Such patients require urgent referral.

If the patient is already known to have diabetic retinopathy then the most likely diagnosis is vitreous haemorrhage, secondary to proliferative disease. This is by no means certain, however, as diabetics may lose vision for many different reasons, including a retinal detachment. If the diagnosis is virtually certain – for example, the patient has had multiple previous episodes and has sustained a further attack of painless visual loss – then there is less urgency about the referral. Such patients may be managed conservatively and attend their routine outpatient follow-up appointment if this is within the next few weeks. By that time, some of the blood may have settled enough to allow laser treatment.

If the patient is a known diabetic but is not under follow-up at the hospital, they should be referred urgently.

What will the hospital do?

It is important for the hospital to ensure that there is no retinal detachment by ultrasound scanning of the globe.

Once this has been ascertained, the further management depends upon the cause. The most likely cause is rupture of some of the new vessels associated with diabetic proliferative retinopathy. If the patient has had previous pan-retinal argon laser treatment, the decision might be to wait for the haemorrhage to resolve. Alternately, early surgery may be indicated, namely a vitrectromy to remove the blood, thereby restoring vision and allowing laser treatment to be given.

Laser treatment requires the retina to be visible, and thus some resolution of the haemorrhage.

What do I need to do?

If the patient has diabetic retinopathy then they have probably developed proliferative disease with neovascularisation of the retina. Their diabetic control needs addressing and optimising.

What to tell the patient

They have had a bleed that is related to the abnormal retinal blood vessels caused by their diabetes. They need further laser treatment to remove the remaining ischaemic retina. If the vision does not improve, they may need an operation to clear out the blood.

Problems that may arise, and how to deal with them

Further haemorrhage is a concern.