What is the treatment for retinal hemorrhages?

Treatment for Retinal Hemorrhages

The treatment for retinal hemorrhages must be tailored to the underlying cause, with immediate referral to a stroke center being essential for retinal artery occlusions, while anti-VEGF therapy is the first-line treatment for macular edema associated with retinal vein occlusions.

Diagnosis and Initial Management

• B-scan ultrasonography is recommended when media opacity (such as vitreous hemorrhage) precludes adequate examination of the peripheral retina to identify underlying causes 1
• Even with dense hemorrhage obscuring the posterior pole, peripheral retina can often be examined using indirect ophthalmoscopy and scleral depression 1
• Bilateral patching and/or elevation of the head while sleeping may help clear vitreous hemorrhage in some cases 1

Treatment Based on Etiology

Retinal Artery Occlusions (RAO)

• For central or branch retinal artery occlusions, immediate referral to a stroke center for urgent evaluation is essential as these represent ocular emergencies 2
• Patients with RAO should be considered similar to those with transient ischemic attacks (TIAs) and require prompt stroke workup 2
• For patients seen within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (tPA) may be considered, as observational data shows 50% rate of clinical recovery when treated within this timeframe 2
• Traditional treatments such as digital massage, anterior chamber paracentesis, vasodilation, breathing into a paper bag, or carbogen therapy have not demonstrated significant benefit compared to natural history 2

Retinal Vein Occlusions (RVO)

• For macular edema associated with branch retinal vein occlusion (BRVO):
  • Anti-VEGF injections are first-line therapy 2
  • Focal laser treatment and intravitreal steroids are alternative options 2
• For macular edema associated with central retinal vein occlusion (CRVO):
  • Anti-VEGF agents (ranibizumab and aflibercept are FDA-approved; bevacizumab is used off-label) 2
  • Intravitreal corticosteroids are considered second-line due to side effects like secondary glaucoma and cataract formation 2
• For neovascularization following RVO:
  • Dense peripheral panretinal photocoagulation (PRP) is indicated 2
  • Anti-VEGF agents can be used adjunctively when PRP is insufficient to control angiogenesis 2

Vitreous Hemorrhage

• For dense posterior vitreous detachment (PVD)-associated vitreous hemorrhage, early vitrectomy (within 7 days) may be beneficial 1
• 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 with vitreous hemorrhage, early vitrectomy should be considered particularly when severe hemorrhage prohibits laser photocoagulation of active neovascularization 1

Subretinal Hemorrhage

• Small amounts of intraretinal hemorrhage may clear without adverse visual sequelae within 4-8 weeks 3
• Small subretinal hemorrhages may clear with minimal vision loss within 3-6 months 3
• Larger subretinal hemorrhages may cause more damage due to iron toxicity to photoreceptors, mechanical damage to retinal pigment epithelium, and cellular proliferation in the subretinal space 3

Special Considerations

• Peripheral retinal hemorrhages may have various etiologies including senescence, systemic and retinal vascular disease, hematologic disorders, infectious disease, and hypoxia 4
• Posterior retinal breaks in diabetic patients can cause vitreous hemorrhage even in the absence of proliferative disease and may require barrier photocoagulation 5
• When a retinal tear is suspected but not visualized due to hemorrhage, repeat ultrasonographic examination should be performed within 1-2 weeks 1

Follow-up Protocol

• Patients with retinal hemorrhage sufficient to obscure retinal details should be followed weekly until hemorrhage resolves or until thorough examination can be performed 1
• For retinal vein occlusions, regular monitoring for development of macular edema and neovascularization is essential 2
• Patients with retinal or vitreous hemorrhage have increased risk of multiple retinal tears and require careful monitoring 1

Prevention

• Optimal control of blood pressure, diabetes, and other risk factors through coordination with the patient's primary care physician is essential for preventing recurrent retinal hemorrhages, especially in cases of RVO 2
• For patients with retinal vein occlusions, measures should be taken to reduce risk of similar events in the same or fellow eye and to reduce risk of potentially life-threatening associated systemic conditions such as stroke or myocardial infarction 6