What is the treatment for vitreous hemorrhage?

Treatment for Vitreous Hemorrhage

The treatment for vitreous hemorrhage depends on the underlying cause, with early vitrectomy (within 7 days) recommended for dense vitreous hemorrhage to reduce the risk of vision loss from macula-involving retinal detachment, while observation with head elevation is appropriate for milder cases that may clear spontaneously. 1

Initial Management and Evaluation

• B-scan ultrasonography should be performed if media opacity precludes adequate examination of the peripheral retina to search for retinal tears, retinal detachment, mass lesions, or other causes of vitreous hemorrhage 1
• Even with dense vitreous hemorrhage obscuring the posterior pole, the peripheral retina can often be examined using indirect ophthalmoscopy and scleral depression 1
• Bilateral patching and/or elevation of the head while sleeping may be used to help clear vitreous hemorrhage 1
• Patients with vitreous hemorrhage sufficient to obscure all retinal details and negative B-scan ultrasonography should be followed weekly until the hemorrhage resolves or until a thorough examination can be performed 1

Treatment Based on Underlying Cause

Posterior Vitreous Detachment (PVD)-Associated Hemorrhage

• For mild to moderate PVD-associated vitreous hemorrhage: observation with frequent follow-up examinations (every 1-2 weeks initially) 1
• For dense PVD-associated vitreous hemorrhage: early vitrectomy (within 7 days of presentation) has been reported to have a low rate of complications and may reduce the risk of vision loss from macula-involving retinal detachment 1
• Prompt intervention is indicated if a retinal tear is seen on ultrasonography and the vitreous cavity precludes a view 1

Diabetic Vitreous Hemorrhage

• For patients with type 1 diabetes and severe vitreous hemorrhage: early vitrectomy shows significant benefit (36% vs 12% achieving visual acuity of 20/40 or better compared to deferral) 1
• For patients with type 2 diabetes: the advantage of early vitrectomy is less pronounced, but should be considered particularly when severe vitreous hemorrhage prohibits laser photocoagulation of active neovascularization 1
• Early vitrectomy is beneficial for patients with visual acuity of 20/400 or better plus severe neovascularization and fibrous proliferation, fibrous proliferation with moderate vitreous hemorrhage, or moderate neovascularization with severe fibrous proliferation and moderate vitreous hemorrhage 1

Surgical Considerations

• Modern vitreoretinal surgical advances have likely improved outcomes beyond those reported in older studies, including small-gauge vitrectomy technology, endoscopic laser photocoagulation, and advanced instrumentation 1
• The use of long-acting intraocular gases (SF6, C3F8), viscodissection, and heavier-than-water liquids like perfluoro-octane have enhanced surgical outcomes 1
• For vitreous hemorrhage with neovascularization, panretinal photocoagulation (PRP) is indicated, sometimes facilitated by anti-VEGF injections to optimize visualization when hemorrhage limits visibility 1

Follow-up Protocol

• When a retinal tear is suspected but not visualized due to hemorrhage, repeat ultrasonographic examination should be performed within 1-2 weeks of initial evaluation 1
• The sensitivity of B-scan ultrasonography for detecting retinal tears in cases of PVD-associated fundus-obscuring vitreous hemorrhage varies considerably (44%-100%) 1
• Patients with retinal or vitreous hemorrhage have an increased risk of multiple retinal tears and require careful monitoring 1

Complications and Prevention

• Complications of untreated vitreous hemorrhage may include glaucoma (ghost cell glaucoma, hemosiderotic glaucoma), proliferative vitreoretinopathy, and hemosiderosis bulbi 2, 3
• Preventative measures depend on the underlying cause, though some causes like posterior vitreous detachment cannot be prevented 4
• For causes like retinal vein occlusion, measures should be taken to reduce the risk of similar events in the same or fellow eye 4

The management approach should be guided by the most likely cause, severity of hemorrhage, and patient factors, with the primary goal of preserving vision and preventing complications.