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QUESTION
HOW DO I WORK UP AND MANAGE A PATIENT WITH A VITREOUS HEMORRHAGE?
Pauline T. Merrill, MD
Marina Gilca, MD
When evaluating a patient with a vitreous hemorrhage, the first step is to obtain a thorough history and perform a complete ophthalmic exam. On history, it is important to pay attention to specific ocular symptoms (eg, photopsias) or predisposing ocular conditions (eg, macular degeneration, myopia, retinal vein occlusion, macroaneurysm). The circumstances of vision loss may give additional clues (eg, trauma, valsalva). The past medical history may be notable for vascular systemic conditions, such as diabetes, hypertension, atherosclerosis, sickle cell anemia, or medications that could predispose to bleeding, including the newer oral anticoagulants (ie, rivaroxaban, apixaban, dabigatran). In children, there may be a history of retinopathy of prematurity, congenital/hereditary conditions associated with peripheral neovascularization (eg, Norrie disease, familial exudative vitreoretinopathy), or nonaccidental trauma.
On examination, visual acuity may correlate with the severity of the vitreous hemorrhage and/or the underlying pathology. The intraocular pressure may be low due to a retinal detachment or high due to neovascular glaucoma and may influence the timing of treatment. Important anterior segment findings include neovascularization of the iris or angle. Dilated ophthalmoscopic examination of both eyes allows you to evaluate the density of the hemorrhage as well as the underlying cause. If there is any view to the peripheral retina, look for retinal breaks or detachment with scleral depression. Areas of the fundus obscured by hemorrhage should be evaluated with B-scan ultrasonography. In addition to detecting a posterior vitreous detachment, flap tear, or retinal detachment, ultrasonography is also helpful in ruling out uncommon but important etiologies such as intraocular tumors. Fluorescein angiography may demonstrate abnormalities, such as neovascularization, ischemia, or macroaneurysm, not only in the fellow eye but also in eyes with mild or moderate vitreous hemorrhage.
Treatment of vitreous hemorrhage traditionally has included observation, with positioning and activity restrictions, to allow settling of the hemorrhage or pars plana vitrectomy. More recently, pharmacologic approaches to clearing vitreous hemorrhage have become available. The timing of treatment is dependent on the underlying etiology, comorbidities, and status of the fellow eye.
When vitreous hemorrhage is due to trauma, associated ocular injuries may dictate the urgency of vitrectomy. In the absence of significant direct ocular trauma (eg, Terson syndrome associated with intracranial hemorrhage), initial observation for spontaneous clearing is often appropriate. As many trauma patients are often younger, however, the risk of amblyopia may be an indication for early vitrectomy in children with vitreous hemorrhage.
In cases of vitreous hemorrhage associated with posterior vitreous detachment, over half will have a retinal break, with almost 90% of the tears located in the superior quadrants.1 When possible, bilateral patching and bed rest with elevation of the head has been shown to allow visualization of the superior retina within a few days in the majority of cases.2 If a retinal break or detachment is identified and the view is adequate, immediate laser or cryopexy may be performed in the office. Otherwise, prompt vitrectomy and/or scleral buckling should be performed. In the absence of a retinal break or detachment, observation with serial B-scan ultrasonography may be continued. Early vitrectomy should be considered for monocular persons or for eyes with hemolytic or ghost cell glaucoma. Vitrectomy has also traditionally been recommended for chronic vitreous hemorrhage lasting more than 3 to 6 months. With the faster healing associated with small-gauge vitrectomy, there is a trend toward earlier intervention.
The treatment approach is similar for vitreous hemorrhage due to vascular causes, such as diabetic retinopathy or retinal vein occlusion. In these cases, an important additional indication for early intervention is neovascular glaucoma. If the view does not allow adequate panretinal laser photocoagulation, prompt vitrectomy should be considered. Alternatively, inhibitors of vascular endothelial growth factor (VEGF) have been shown to induce rapid regression of neovascularization.3 Intravitreal anti-VEGF injections, such as bevacizumab, have also been found to hasten clearing of vitreous hemorrhage,4 and thus potentially serve a dual role in eyes with rubeosis and vitreous hemorrhage. One must be cautious, however, in cases with extensive retinal neovascularization and vitreoretinal traction. In this situation, intravitreal anti-VEGF injection has been associated with rapid regression of neovascularization and secondary progression of tractional retinal detachment.5 If the B-scan ultrasound examination demonstrates significant traction, I plan for vitrectomy and consider an anti-VEGF injection a few days preoperatively. This helps to minimize hemorrhage both intra- and postoperatively. Patient compliance and a stable systemic status are important considerations when planning for a preoperative intravitreal bevacizumab injection.
Another potential pharmacologic treatment for vitreous hemorrhage was evaluated in the Vitrase for Vitreous Hemorrhage study. In this study, highly-purified bovine hyaluronidase demonstrated efficacy in clearing vitreous hemorrhage sufficiently to allow treatment of the underlying pathology by 3 months.6 Vitrase did not, however, receive US Food and Drug Administration approval for this indication.
Summary
Patients with vitreous hemorrhage should be evaluated carefully for the presence of retinal breaks or detachment, neovascularization of the iris or angle, glaucoma, and intraocular tumors. In the absence of these pathologies, most vitreous hemorrhages may be safely observed. When indicated, however, pharmacologic and/or surgical intervention may allow treatment of the underlying cause and may also speed visual improvement for your patient.
Acknowledgment of Significant Collaboration
Molly Weiner, MD
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