What is the treatment for vitreous hemorrhage?

Treatment for Vitreous Hemorrhage

The treatment of vitreous hemorrhage depends critically on the underlying cause and severity, with early vitrectomy (within 7 days) recommended for dense posterior vitreous detachment-associated hemorrhage, and immediate intervention for diabetic patients with type 1 diabetes showing significant visual benefit over observation. 1

Initial Evaluation and Diagnostic Approach

Perform B-scan ultrasonography immediately when vitreous hemorrhage prevents adequate visualization of the peripheral retina to identify retinal tears, detachment, mass lesions, or other causative pathology. 1 Even with dense hemorrhage obscuring the posterior pole, examine the peripheral retina using indirect ophthalmoscopy with scleral depression. 1

Conservative Management During Evaluation

• Bilateral patching and head elevation while sleeping may facilitate hemorrhage clearance in select cases. 1
• If B-scan ultrasonography is negative and hemorrhage obscures all retinal details, follow weekly until hemorrhage resolves or adequate examination becomes possible. 1
• When retinal tears are suspected but not visualized, repeat ultrasonography within 1-2 weeks, as B-scan sensitivity for detecting tears varies considerably (44%-100%). 1

Treatment Based on Underlying Etiology

Diabetic Vitreous Hemorrhage

For type 1 diabetes with severe vitreous hemorrhage, perform early vitrectomy as it demonstrates significant benefit (36% vs 12% achieving 20/40 or better visual acuity compared to deferral). 1

For type 2 diabetes, early vitrectomy should be strongly considered particularly when severe hemorrhage prevents laser photocoagulation of active neovascularization, though the advantage is less pronounced than in type 1 diabetes. 1

Panretinal Photocoagulation (PRP) Protocol

• Most patients with high-risk proliferative diabetic retinopathy should receive PRP expeditiously as it substantially reduces severe visual loss risk and induces regression of retinal neovascularization. 2
• Full PRP includes 1200-1600 spots of moderate burns, 0.1 second duration, one-half burn width apart, at least 2 disc diameters from the fovea extending to the equator. 2
• Fluorescein angiography is not usually necessary for effective PRP application. 2

Anti-VEGF Therapy Considerations

Anti-VEGF injections (ranibizumab) are noninferior to PRP at 2 years and result in less macular edema worsening and peripheral vision loss. 2 However, this approach requires reliable patient follow-up, as patients lost to follow-up have inferior outcomes compared to PRP. 2

Consider additional PRP or anti-VEGF therapy when:

• Neovascularization fails to regress 2
• Increasing neovascularization of retina or iris develops 2
• New vitreous hemorrhage occurs 2
• New areas of neovascularization appear 2

Posterior Vitreous Detachment-Associated Hemorrhage

For dense PVD-associated vitreous hemorrhage, perform early vitrectomy within 7 days of presentation, as this approach has low complication rates and may reduce vision loss risk from macula-involving retinal detachment. 1

Involutional PDR with Vitreous Hemorrhage

In involutional proliferative diabetic retinopathy, vitreous hemorrhage may result from vitreous traction on involuted neovascularization. These eyes may not require additional PRP, especially when venous dilation is absent. 2

Surgical Indications for Pars Plana Vitrectomy

Consider pars plana vitrectomy for:

• Vitreous opacities interfering with vision or treatment 2
• Severe fibrovascular proliferation 2
• Traction retinal detachment threatening or involving the macula 2
• The value of early vitrectomy increases with increasing neovascularization severity 2

Modern surgical advances including small-gauge vitrectomy, endoscopic laser photocoagulation, long-acting intraocular gases (SF6, C3F8), viscodissection, and perfluoro-octane have enhanced outcomes beyond older studies. 1

Common Pitfalls and Caveats

Critical warning: Patients with retinal or vitreous hemorrhage have increased risk of multiple retinal tears requiring careful ongoing monitoring. 1

Do not choose anti-VEGF monotherapy over PRP unless you can ensure reliable patient follow-up, as loss to follow-up results in significantly worse visual and anatomic outcomes. 2

Partial or limited PRP is not a proven treatment approach—only full PRP has demonstrated efficacy in reducing severe vision loss risk. 2

For type 2 diabetes patients with severe NPDR to non-high-risk PDR, early PRP reduces severe vision loss or vitrectomy risk by 50% (2.5% vs 5%) compared to deferring until high-risk PDR develops. 2