What is the management and treatment of retinal hemorrhage found on fundoscopic exam?

Management of Retinal Hemorrhage on Fundoscopic Exam

The management of retinal hemorrhage depends critically on identifying the underlying etiology through immediate comprehensive examination, with treatment ranging from urgent stroke evaluation for arterial occlusions to anti-VEGF therapy for venous occlusions, or early vitrectomy for dense vitreous hemorrhage obscuring vision-threatening pathology. 1

Immediate Diagnostic Evaluation

Initial Examination Requirements

• Perform B-scan ultrasonography immediately if media opacity or hemorrhage prevents adequate visualization of the peripheral retina to identify retinal tears, retinal detachment, mass lesions, or other causes 2, 1
• Even with dense hemorrhage obscuring the posterior pole, examine the peripheral retina using indirect ophthalmoscopy with scleral depression, as this is often still possible 2, 1
• Assess visual acuity, pupillary response (relative afferent pupillary defect indicates ischemia level), intraocular pressure, and perform gonioscopy prior to dilation 2
• Use optical coherence tomography (OCT) to detect macular edema, vitreoretinal interface changes, and neurosensory detachment 2

Determining the Etiology

The treatment algorithm diverges completely based on whether the hemorrhage originates from:

• Retinal artery occlusion (requires emergency stroke evaluation)
• Retinal vein occlusion (requires anti-VEGF or laser therapy)
• Vitreous hemorrhage from posterior vitreous detachment (may require early vitrectomy)
• Other causes (trauma, macroaneurysm, systemic disease)

Management Based on Etiology

Retinal Artery Occlusions (Medical Emergency)

• Immediately refer to a stroke center or emergency department within 24 hours of symptom onset—do not delay for outpatient workup 3
• These patients should be treated identically to transient ischemic attack patients, as up to 24% have concurrent cerebrovascular accident on MRI 3
• For patients presenting within 4.5 hours of symptom onset, intravenous tissue plasminogen activator (alteplase 0.9 mg/kg) may be considered, with observational data showing 50% clinical recovery when treated within this timeframe 1, 3
• Traditional treatments (digital massage, anterior chamber paracentesis, vasodilation, breathing into paper bag, carbogen therapy) have not demonstrated benefit compared to natural history 1
• If giant cell arteritis is suspected, initiate immediate steroid therapy to preserve vision in the contralateral eye 3

Retinal Vein Occlusions

For Branch Retinal Vein Occlusion (BRVO):

• Anti-VEGF injections are first-line therapy for macular edema 1
• Focal laser treatment and intravitreal steroids are alternative options 1
• For neovascularization, perform dense peripheral panretinal photocoagulation (PRP) 1
• Use anti-VEGF agents adjunctively when PRP is insufficient to control angiogenesis 1

For Central Retinal Vein Occlusion (CRVO):

• Anti-VEGF agents are first-line for macular edema 1
• Intravitreal corticosteroids are second-line due to side effects including secondary glaucoma and cataract formation 1
• Perform gonioscopy to monitor for iris neovascularization, especially with elevated IOP or ischemic CRVO 2
• Regular monitoring with OCT for macular edema development is essential 2, 1

Vitreous Hemorrhage

Conservative Management:

• Bilateral patching and/or head elevation while sleeping may help clear vitreous hemorrhage 2, 1, 4
• Follow patients weekly until hemorrhage resolves or thorough examination can be performed 1, 4
• When retinal tear is suspected but not visualized, repeat B-scan ultrasonography within 1-2 weeks 2, 1, 4

Surgical Intervention:

• For dense posterior vitreous detachment-associated vitreous hemorrhage, consider early vitrectomy within 7 days to reduce risk of vision loss from macula-involving retinal detachment 1, 4
• For type 1 diabetes patients with severe vitreous hemorrhage, early vitrectomy shows significant benefit (36% vs 12% achieving 20/40 or better visual acuity compared to deferral) 1, 4
• For type 2 diabetes, early vitrectomy should be considered particularly when severe hemorrhage prevents laser photocoagulation of active neovascularization 1, 4
• Prompt intervention is indicated if a tear is seen on ultrasonography and the vitreous cavity precludes adequate view 2

Follow-Up Protocol

Monitoring Schedule

• Patients with hemorrhage obscuring retinal details require weekly follow-up initially until resolution or adequate examination can be performed 2, 1, 4
• For retinal vein occlusions, regular monitoring for macular edema and neovascularization development is essential 1
• Patients with retinal or vitreous hemorrhage have increased risk of multiple retinal tears requiring careful monitoring 2, 1, 4

Imaging Considerations

• B-scan ultrasonography sensitivity for detecting retinal tears in fundus-obscuring vitreous hemorrhage varies considerably (44%-100%) 2, 4
• Wide-field color photography can detect some peripheral retinal breaks but does not replace careful ophthalmoscopy 2
• Fluorescein angiography can evaluate extent of vascular occlusion, degree of ischemia, and type of macular edema, though its use has declined with increased anti-VEGF therapy 2

Critical Pitfalls to Avoid

• Never delay emergency department referral for retinal artery occlusions to obtain outpatient workup—the stroke risk is highest within the first 7 days 3
• Do not assume hemorrhage is benign even if asymptomatic; peripheral retinal hemorrhages have various potential etiologies requiring identification 5
• B-scan ultrasonography has variable sensitivity for retinal tears, so maintain high clinical suspicion and repeat imaging if initial study is negative 2, 4
• Optimal control of blood pressure, diabetes, and other vascular risk factors through coordination with primary care is essential for preventing recurrent hemorrhages 1
• Up to 70% of patients with symptomatic central retinal artery occlusion have a new significant systemic cardiovascular condition discovered (typically clinically significant carotid stenosis) 3