Vitreous Haemorrhage
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Direct answer
Vitreous haemorrhage is bleeding into the vitreous cavity, presenting as sudden painless floaters — "cobwebs", "soot", or a red haze — with visual loss ranging from mild blur to perception of light, and a fundus view that is reduced or abolished with a poor or absent red reflex. The major causes are proliferative diabetic retinopathy (the commonest worldwide and in India), a retinal tear or posterior vitreous detachment in the older eye, trauma, vein occlusion, macroaneurysm, sickle cell retinopathy and Eales disease — the last a periphlebitis of young Indian men presenting with recurrent vitreous haemorrhages. When no fundus view exists, B-scan ultrasonography rules out retinal tear, detachment and tumour; management is upright rest with avoidance of anticoagulants, treating the underlying retinopathy with photocoagulation when the view allows, and pars plana vitrectomy for non-clearing haemorrhage, traction or detachment.
What you must remember
- Presentation: sudden painless floaters and decreased vision; a "shower" of dark spots with flashes suggests a retinal tear until proved otherwise; vision may be 6/6 behind a small bleed or hand movements behind a dense one — pain is absent unless there is accompanying pathology.
- Causes by demographic: older patient — posterior vitreous detachment with retinal tear, branch vein occlusion, exudative macular degeneration; younger patient — proliferative diabetic retinopathy (the largest single cause in India), Eales disease, sickle cell retinopathy, trauma; any age — penetrating injury, and Terson syndrome (sub-internal limiting membrane blood after subarachnoid haemorrhage — check the neurology, and remember bilateral paediatric haemorrhage with abuse).
- Eales disease: idiopathic retinal periphlebitis of young healthy men, with sheathing of peripheral veins, capillary non-perfusion and recurrent vitreous haemorrhages; managed with sector photocoagulation and vitrectomy for non-clearing bleeds — an examinable Indian entity.
- The B-scan rule: no fundus view means ultrasound, serially if needed — to exclude retinal detachment (which changes timing to urgent surgery), a concealed retinal tear, or an intraocular tumour bleeding into the vitreous.
- Conservative management: upright posture to let blood settle, avoidance of aspirin and anticoagulants where possible, and scheduled review — a dense bleed may take weeks to months to clear.
- Laser the cause when possible: panretinal photocoagulation through a partial haemorrhage in proliferative diabetic or Eales disease removes the neovascular drive that will otherwise re-bleed.
- Surgery indications: non-clearing haemorrhage (commonly beyond one to three months), associated tractional or rhegmatogenous retinal detachment, macular traction, rubeosis, or an undiagnosable fundus despite ultrasound.
- Signs at the slit lamp: dull red reflex, cells and layered blood in the anterior vitreous, and ghost-cell glaucoma — a late pressure rise when degenerated red cells block the trabecular meshwork.
How to work through a "curtain of black blobs"
A 34-year-old man who has never seen a physician reports sudden "soot-like" floaters and vision of 6/36 for two days, no pain, no trauma. Establish the systemic frame — random glucose and blood pressure, because silent proliferative retinopathy is the leading possibility in India; examine the periphery of both eyes with indirect ophthalmoscopy and indentation, since Eales and diabetic proliferative disease are frequently bilateral. The right eye view is hazy but present: sheathed peripheral veins with haemorrhages and pale avascular periphery — Eales disease. Photograph and plan sector photocoagulation of the ischaemic periphery once the blood settles, upright posture meanwhile. Contrast the emergency variant: a 65-year-old with flashes preceding a floaters shower and a B-scan showing a mobile posterior vitreous with an operculated superior tear and shallow subretinal fluid — that combination is urgent laser or vitrectomy-buckling surgery, because the tear has declared itself and the retina is beginning to lift; the two cases share the symptom and split on the ultrasound that stands between watchful waiting and the operating theatre.
Where students slip
The first error is prescribing "rest and review" for every vitreous haemorrhage without ultrasound: the unseen retinal detachment under a dense bleed is the complication that converts a recoverable eye to a blind one, and serial B-scans are the standard of care. The second is forgetting Terson syndrome in the confused patient after subarachnoid haemorrhage — bilateral vitreous haemorrhage there is a recognised association and ophthalmology may be the first service to detect the neurologic event. The third is missing ghost-cell or haemolytic glaucoma in the follow-up: a haemorrhagic eye with rising pressure weeks later is not a re-bleed by default, and the anterior chamber full of khaki-coloured cells names it.
Frequently asked questions
What is the commonest cause of vitreous haemorrhage in India?
Proliferative diabetic retinopathy, with ruptured neovascularisation; Eales disease is the classic cause in young non-diabetic men with recurrent unilateral or bilateral bleeds.
Which investigation is mandatory when the fundus cannot be visualised?
B-scan ultrasonography — to detect retinal detachment, a hidden retinal tear, or an intraocular mass, repeated serially while the haemorrhage clears.
What is Eales disease?
An idiopathic obliterative retinal periphlebitis of young adults, predominantly Indian men, causing peripheral venous sheathing, ischaemia, neovascularisation and recurrent vitreous haemorrhages.
When is vitrectomy indicated for vitreous haemorrhage?
Non-clearing haemorrhage over roughly one to three months, associated tractional or rhegmatogenous detachment, macular traction, rubeosis, or an undiagnosable fundus despite imaging.
What is ghost-cell glaucoma?
A late pressure rise after vitreous haemorrhage in which degenerated, less-pliable red blood cells migrate into the anterior chamber and obstruct trabecular meshwork outflow.