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Ocular System

Vitreous hemorrhage (VH)

Presence of extra-vasated blood within the space outlined by the internal limiting membrane of the retina posteriorly and laterally, the non-pigmented epithelium of the ciliary body laterally, and the lens zonular fibers and posterior lens capsule anteriorly.

Presence of extra-vasated blood within the space outlined by the internal limiting membrane of the retina posteriorly and laterally, the non-pigmented epithelium of the ciliary body laterally, and the lens zonular fibers and posterior lens capsule anteriorly.


Aetiology

Proliferative Vascular Retinopathy:

Bleeding occurs from neovascularization due to retinal ischemia causing elevated angiogenic factors
  • Proliferative diabetic retinopathy (PDR) (M/C cause of bilateral VH)
  • Retinal vein occlusion (RVO)
  • Vasculitis (Eales disease, and others)
  • Pars planitis
  • Sickle cell retinopathy
  • Retinopathy of prematurity (ROP)

Trauma:

M/C cause of VH in < 40 years

Less common causes:

  • Vascular occlusive disease
  • Retinal arterial macroaneurysm
  • Hemoglobinopathies
  • Age-related macular degeneration
  • Intraocular tumors
  • Shaken baby syndrome

Clinical features

  • Early/mild VH: Floaters, cobwebs, haze, shadows or a red hue
  • Advanced VH: Sudden painless decrease in vision

Complications

  • Hemosiderosis Bulbi
  • Glial and Fibrivascular Proliferation
  • Glaucoma:
    • Ghost cell glaucoma
    • Haemolytic glaucoma
    • Haemosiderotic glaucoma

Diagnosis

Ocular ultrasound:

Find out the etiology as well as the characteristics of hemorrhage
  • Fresh VH/VH in vitrectomised eye: Multiple echolucent or low reflective dot-like echoes (RBCs), better visualized in high gain.
  • Long-standing VH: Dot like echoes forming a highly reflective membrane over a period of time, denser inferiorly.
  • Subhyaloid hemorrhage: Multiple dot-like echoes behind a mobile (with ocular movements) and thin membrane (posterior vitreous detachment, PVD).

Optical Coherence Tomography (OCT)

Differentiate between subhyaloid or sub ILM bleed while planning treatment

Fundus Fluorescein Angiography (FFA)/ Indocyanine Green Angiography (ICGA)

Helps in localizing areas with capillary non-perfusion and neovascularisation, to plan laser therapy

Differential diagnosis:

  • Vitritis
  • Primary intraocular lymphoma
  • Asteroid hyalosis
  • Retinal Detachment (RD)

Management

Conservative management:

In cases with unknown causes and fresh VH with an attached retina cases
  • Observation
  • Regimen of bed rest and head elevation (facilitate settling of the blood)
  • Oral ascorbic acid (Vitamin C)

Laser photocoagulation

For proliferative retinopathies
  • Panretinal photocoagulation (PRP): Mainstay treatment in PDR
    • Reduces the release of angiogenic factors (vascular endothelial growth factor/VEGF, platelet-derived growth factor/PDGF) by converting ischemic retina into anoxic.

Anterior retinal cryotherapy (ARC)

ARC causes breakdown of blood-retinal barrier, which in turn leads to the clearance of liquefied blood

Pars Plana Vitrectomy (PPV)

VH associated with retinal detachment (RD), endophthalmitis, long-standing hemorrhage, open globe injury, VH due to neovascular AMD/IPCV, one-eyed patients, bilateral cases, secondary glaucoma (ghost cell, hemolytic, hemosiderotic glaucoma), children who are at risk of developing amblyopia are indications for surgery

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