Vitreous Hemorrhage Workup in the Emergency Department
Patients presenting with vitreous hemorrhage to the ED require immediate dilated fundoscopic examination with slit-lamp biomicroscopy and indirect ophthalmoscopy to identify retinal tears or detachment, and if the view is obscured, B-scan ultrasonography must be performed—with urgent ophthalmology consultation for all cases given that 62-75% have underlying retinal tears or detachments at presentation. 1, 2
Critical Initial Assessment
History Elements to Obtain
- Onset and duration of visual symptoms (floaters, flashes, vision loss)
- Trauma history (even minor)
- Recent ocular procedures (intravitreal injections, cataract surgery)
- Systemic conditions: diabetes, hypertension, bleeding disorders, anticoagulation use
- Prior retinal problems or lattice degeneration 1, 3
Physical Examination Protocol
Visual acuity measurement in both eyes is mandatory first step 3, 4
Pupillary assessment for relative afferent pupillary defect—indicates significant retinal ischemia or detachment 3, 4
Intraocular pressure measurement—elevated IOP may indicate secondary angle-closure glaucoma from vitreous hemorrhage 5
Dilated fundoscopic examination using:
- Slit-lamp biomicroscopy with appropriate lenses for posterior pole
- Indirect ophthalmoscopy with scleral depression for peripheral retina examination 1, 3
Look specifically for:
- Retinal tears or detachment (most critical finding)
- Vitreous pigment (Shafer's sign—indicates retinal tear)
- Posterior vitreous detachment (Weiss ring)
- Neovascularization of disc or elsewhere
- Extent and location of hemorrhage 1
Imaging
B-Scan Ultrasonography
Perform immediately if fundus view is obscured by hemorrhage 6, 7, 8
Critical caveat: B-scan has only 53.6% sensitivity for detecting retinal tears/detachments—a negative ultrasound does NOT rule out these sight-threatening conditions 2
Ultrasound findings to identify:
- Retinal detachment (appears as hyperechoic membrane)
- Vitreous hemorrhage (low-level echoes in vitreous cavity)
- Posterior vitreous detachment
- Lens dislocation 7, 9
Pitfall: Asteroid hyalosis can mimic vitreous hemorrhage on ultrasound but appears as multiple discrete, mobile hyperechoic foci rather than diffuse low-level echoes 10
Risk Stratification
High-Risk Features Requiring URGENT Ophthalmology Consultation (within hours):
- Any degree of vitreous pigment (tobacco dust)
- Visible vitreoretinal traction
- Retinal tear or detachment identified
- Recent posterior vitreous detachment (within 6 weeks)
- Elevated intraocular pressure 1, 5
Moderate-Risk Features:
- Dense hemorrhage obscuring fundus view
- History of lattice degeneration
- High myopia
- Recent cataract surgery
- Diabetes with proliferative retinopathy 1, 8
Disposition and Consultation
All patients with vitreous hemorrhage require ophthalmology consultation—the only question is timing 1, 2
Emergent consultation (same day): Any high-risk features listed above, as 8-22% of acute posterior vitreous detachments have retinal tears at initial presentation 1
Urgent consultation (within 24-48 hours): Fundus-obscuring hemorrhage even without identified high-risk features, given that B-scan misses nearly half of tears/detachments 2
Follow-up Protocol
Patients with acute posterior vitreous detachment and no retinal breaks identified still have 2-5% risk of developing tears in subsequent weeks—they require re-examination within 6 weeks or immediately if new symptoms develop 1
Common Pitfalls to Avoid
Relying solely on B-scan: 46.4% of retinal tears/detachments are missed on ultrasound 2
Delaying examination: Traditional "observation" approach is outdated—only 25% of severe vitreous hemorrhages clear spontaneously, while 75% ultimately require vitrectomy 2
Missing secondary angle-closure: Always measure IOP, especially after intravitreal injections 5
Inadequate peripheral examination: Most retinal tears occur in periphery—indirect ophthalmoscopy with scleral depression is essential when view permits 1
Confusing asteroid hyalosis with hemorrhage: Look for discrete mobile echoes versus diffuse low-level echoes 10