What are the treatment options for vitreal (vitreous) hemorrhage?

Treatment Options for Vitreous Hemorrhage

The primary treatment options for vitreous hemorrhage include observation for spontaneous clearing, early vitrectomy within 7 days for dense hemorrhage, anti-VEGF injections as adjunctive therapy, and addressing the underlying cause through laser photocoagulation or other targeted interventions. 1, 2

Initial Management Approach

Diagnostic Assessment

• B-scan ultrasonography: Essential when vitreous hemorrhage obscures retinal details
  • Look for: Low to medium reflective mobile echoes that swirl with eye movement (characteristic of vitreous hemorrhage)
  • Rule out: Retinal tears, detachments, or other underlying pathologies 1, 2
• Peripheral retinal examination with scleral depression: Should be performed when possible, as peripheral retina can often be examined even when posterior pole is obscured 1

Management Based on Visibility and Underlying Cause

When Retina is Partially Visible:

1. Identify and treat underlying cause:
   • Proliferative diabetic retinopathy: Panretinal photocoagulation and/or anti-VEGF therapy 2, 3
   • Retinal tears: Laser photocoagulation or cryotherapy 4, 3
   • Vascular occlusions: Anti-VEGF therapy and monitoring for neovascularization 2

When Retina is Not Visible (Dense Hemorrhage):

1. Close monitoring:

   • Weekly follow-up until hemorrhage resolves or until thorough examination can be performed 1
   • Repeat ultrasonography within 1-2 weeks if retinal tear is suspected 1

2. Early vitrectomy consideration:

   • Consider vitrectomy within 7 days of presentation for dense PVD-associated vitreous hemorrhage
   • Particularly indicated when:
     • Tear is seen on ultrasonography but view is precluded
     • Risk of vision loss from macula-involving retinal detachment 1, 2

Specific Treatment Modalities

Observation

• Appropriate for mild to moderate hemorrhage without retinal tears or detachment
• Many cases will clear spontaneously, though timeframe varies based on underlying cause
• More favorable natural history in eyes without underlying disease 4

Surgical Management

• Pars plana vitrectomy:
  • Primary indication: Non-clearing vitreous hemorrhage
  • Benefits: Allows direct visualization and treatment of underlying pathology
  • Timing: Consider early intervention (within 7 days) for dense hemorrhage to reduce risk of macula-involving retinal detachment 1, 5
  • Modern surgical techniques have improved outcomes with fewer complications 5

Pharmacologic Management

• Anti-VEGF injections:
  • Role: Primarily as adjunctive therapy, not as primary treatment for the hemorrhage itself
  • Particularly useful when hemorrhage is associated with:
    • Proliferative diabetic retinopathy
    • Neovascularization from vein occlusions
    • To facilitate laser application when visibility is limited 1, 5

Laser Photocoagulation

• Panretinal photocoagulation (PRP):
  • Indicated for proliferative retinopathies (diabetic, post-vein occlusion)
  • May be performed during vitrectomy as endolaser when view is obscured 5
• Focal laser:
  • For retinal tears or localized vascular abnormalities 4, 3

Follow-up and Monitoring

• Regular ultrasonographic evaluation for cases with dense hemorrhage
• Monitor for complications:
  • Neovascular glaucoma
  • Ghost cell glaucoma
  • Hemosiderosis bulbi
  • Proliferative vitreoretinopathy 3

Special Considerations

• Anticoagulation therapy: If patient is on anticoagulants for venous thromboembolism, continue therapy as the benefits outweigh risks 1
• Elderly patients: Require careful evaluation for underlying systemic conditions that may have contributed to hemorrhage 6

Remember that the prognosis and management approach depend heavily on the underlying cause of the vitreous hemorrhage, making proper diagnostic evaluation crucial for optimal outcomes.