Download Approach to a case of Vitreous Hemorrhage

Approach to a case of
vitreous haemorrhage
Sandeep Saxena MS, FRCSEd
Professor
Department of Ophthalmology
KGMU, Lucknow
September 27, 2014
Vitreous Humor
• Inert , transparent, jelly-like structure
• Normal volume- 4ml
• Composed of a network of collagen fibrils
interspersed with hyaluronic acid molecules
• Can be divided into cortex and nucleus
• Attachments
- Vitreous base-strongest adherance about
4mm across the orra serrata
-Around margins of optic disc, foveal region,
along retinal vessels
• Ageing changes-Dissociation of hyaluronate from collagen
fibrils
-Pooling of hyaluronate
-Fibril degeneration and decreased elasticity
-Drainage of hyaluronate into retrovitreal
space (posterior vitreous detachment)
• Vitreous degeneration
- Syneresis
-Vitreous liquefaction, fibril aggregation
and condensation
-Associated with floaters
-Caused by myopia, senescence, trauma,
inflammation, etc.
- Posterior vitreous detachment
Vitreous Haemorrhage
Causes
• Proliferative retinopathies-Diabetes mellitus
-Retinal vein occlusion
-Retinopathy of prematurity
-Eale’s disease
• Rhegmatogenous retinal detachment
• Posterior vitreous detachment
• Trauma
• Systemic – Bleeding disorders
Pathophysiology
• Retinal ischemia causing release of angiogenic
vasoactive factors (like VEGF)
• Tear in retinal vasculature due to break in the
retina or detachment of posterior vitreous
• Subretinal bleeding with secondary extension
into the vitreous cavity- less common
Clinical features
• Symptoms-Sudden appearance of floaters - small vitreous
haemorrhage
-Sudden painless loss of vision- large vitreous
haemorrhage
• Signs- No red glow on distant direct ophthalmoscopy
- Blood in vitreous cavity on indirect
ophthalmoscopy
Patient workup
• Slit lamp examination of the eye
• Pupil dilatation and fundus examination
• B scan ultrasound for posterior segment
evaluation
• Blood tests to check for specific causes such as
diabetes
• CT scan may be required in some cases to
check for injury around the eye
Fate of vitreous haemorrhage
• Complete resolution may occur within 4-8
weeks without organisation with vitreous
• Organisation of haemorrhage with formation
of a yellowish-white debris occurs in
persistent or recurrent bleeding
• Complications like vitreous liquefaction,
degeneration and ghost cell glaucoma may
occur
• Fibrous proliferation may develop which may
be complicated by tractional retinal
detachment
Management
• Conservative management consists of bed
rest with elevation of patient’s head end to
facilitate settlement of blood
• Treatment of cause- Once the blood settles
down, indirect ophthalmoscopy should be
done to locate and further manage the cause
of haemorrhage
• Pars plana vitrectomy may be attempted to
clear the vitreous, if the haemorrhage does
not get absorbed in 3 months
• Early vitrectomy followed by laser
photocoagulation may be required in cases
associated with retinal detachment
Thank you