How to assess for a retinal hemorrhage?

Assessment of Retinal Hemorrhage

The optimal assessment for retinal hemorrhage requires indirect ophthalmoscopy with scleral depression through fully dilated pupils, which is the preferred method for detecting peripheral vitreoretinal pathology and associated hemorrhage. 1

Essential Clinical Examination Components

The comprehensive eye examination for suspected retinal hemorrhage must include:

• Visual acuity testing to establish baseline function and detect any vision loss 1
• Pupillary assessment for relative afferent pupillary defect, which may indicate significant retinal pathology 1
• Examination of the vitreous for hemorrhage, detachment, and pigmented cells using slit-lamp biomicroscopy 1
• Careful peripheral fundus examination using indirect ophthalmoscopy combined with scleral depression, which remains the gold standard technique 1

Alternative Examination Techniques

When indirect ophthalmoscopy with scleral depression is not feasible:

• Slit-lamp biomicroscopy with a mirrored contact lens or condensing lens can be used in fully dilated eyes as an alternative method for examining the peripheral retina 1
• Wide-field color photography can detect some peripheral retinal hemorrhages but does not replace careful ophthalmoscopy and may be useful in patients unable to tolerate the standard examination 1

Advanced Imaging Modalities

When Media Opacity Obscures Direct Visualization

B-scan ultrasonography should be performed when media opacity or patient cooperation precludes adequate examination of the peripheral retina, to search for retinal tears, retinal detachment, mass lesions, or other causes of vitreous hemorrhage 1. The sensitivity of B-scan ultrasonography for detecting retinal pathology in fundus-obscuring vitreous hemorrhage varies considerably (44%–100%) 1.

Optical Coherence Tomography (OCT)

• OCT is extremely valuable for detecting even small macular hemorrhages and can identify paracentral acute middle maculopathy (PAMM), the earliest sign of acute retinal artery occlusion, before other clinical findings appear 2
• OCT combined with wide-field fundus photography (RetCam) provides comprehensive documentation of retinal hemorrhage extent, spread, and morphology, particularly valuable in forensic evaluation 3

Fluorescein Angiography

• Fluorescein angiography definitively documents arterial flow alterations, including delayed arterial filling, areas of capillary nonperfusion, and the extent of retinal vasculature involvement 2
• Important caveat: Severe complications including death occur in approximately 1 per 200,000 patients, requiring informed consent and emergency protocols 2

Critical Time-Sensitive Considerations

Examination Timing

Eye examinations should be completed as soon as possible after admission, preferably within 24-48 hours, to accurately identify hemorrhage patterns and establish timing of injury 4. This is particularly critical because:

• Intraretinal hemorrhages clear rapidly, typically resolving to none or mild within 1-2 weeks 4
• Too-numerous-to-count (TNTC) intraretinal hemorrhages indicate trauma occurred within a few days prior to examination 4
• Preretinal hemorrhages may persist for 5-111 days, whereas isolated intraretinal hemorrhages persist no longer than 32 days 4

Follow-Up Protocol

When vitreous hemorrhage obscures all retinal details and B-scan ultrasonography is negative, patients should be followed closely with weekly examinations until the vitreous hemorrhage resolves or a thorough indirect ophthalmoscopic depressed peripheral exam can be performed 1. When a retinal tear is suspected, repeat ultrasonographic examination should be performed within 1-2 weeks of initial evaluation 1.

Common Pitfalls to Avoid

• Gonioscopy should be performed before dilation when neovascularization of the iris is suspected or intraocular pressure is elevated, as neovascularization can occur up to 4 months after acute arterial occlusion 2
• Do not rely solely on MRI for retinal hemorrhage detection, as it demonstrates only 61% sensitivity despite 100% specificity, with low-grade hemorrhages detected in only 14% of cases compared to 76% for high-grade hemorrhages 5
• Gradient recalled echo (GRE) sequences are the most sensitive MRI sequences for detecting retinal hemorrhages when imaging is performed 5

Special Populations

Pediatric Head Trauma

In children under 2 years with suspected abusive head trauma:

• Full retinal examination through pharmacologically dilated pupils is essential, as retinal hemorrhage is the most frequent and reliable finding of abusive head trauma 3
• The combination of RetCam and OCT imaging provides optimal documentation of hemorrhage extent, spread, and morphology for forensic evaluation 3
• MRI may serve as an adjunct when ophthalmologic expertise is unavailable, with ringlets of hyperintensity in orbital fat on axial fat-suppressed T2-weighted images present in 96% of confirmed retinal hemorrhage cases 6