Overview
Vitreous hemorrhage is a serious eye condition characterized by bleeding into the vitreous cavity, the gel-filled space in the back of the eye between the lens and the retina. The vitreous humor, normally a clear gel that helps maintain the eye's shape and allows light to pass through to the retina, becomes clouded with blood, leading to vision problems ranging from mild floaters to severe vision loss.
This condition affects approximately 7 cases per 100,000 people annually, making it one of the most common causes of acute vision loss. Vitreous hemorrhage can occur at any age but is most frequently seen in adults with underlying vascular conditions, particularly diabetic retinopathy. The severity and impact on vision depend on the amount of bleeding, with small hemorrhages causing minimal symptoms while massive bleeding can result in profound vision loss.
The vitreous cavity contains about 4 milliliters of clear gel composed of 99% water and 1% collagen and hyaluronic acid. When blood vessels in or near the retina rupture, blood can leak into this space, obscuring vision. The condition can be unilateral (affecting one eye) or bilateral (affecting both eyes), though unilateral presentation is more common. Prompt diagnosis and treatment are essential to preserve vision and address underlying causes.
Key Facts About Vitreous Hemorrhage
- Affects 7 per 100,000 people annually
- Leading cause is diabetic retinopathy (30-50% of cases)
- Can cause sudden, painless vision loss
- May clear spontaneously in mild cases
- Severe cases may require surgical intervention
Symptoms
The symptoms of vitreous hemorrhage can vary significantly depending on the amount and location of bleeding. Small hemorrhages may cause minimal symptoms, while large bleeds can result in severe vision impairment. Understanding these symptoms is crucial for early recognition and prompt treatment.
Primary Visual Symptoms
Diminished Vision
Vision loss ranging from mild blurring to complete blindness in the affected eye. Often develops suddenly and painlessly.
Learn more about diminished vision →Floaters and Spots
Dark spots, strings, or cobwebs floating in the visual field. May appear as red or black shadows.
Learn more about visual floaters →Red Tint to Vision
Vision may have a reddish or pinkish hue, especially in the early stages of bleeding.
Learn more about eye symptoms →Light Flashes
Brief flashes of light, particularly in peripheral vision, may precede or accompany hemorrhage.
Associated Symptoms
Additional symptoms that may accompany vitreous hemorrhage include:
- Eye pain - though vitreous hemorrhage is typically painless, underlying conditions may cause discomfort
- Excessive tearing as a reflex response to vision changes
- Photophobia (light sensitivity)
- Difficulty with depth perception
- Complete blindness in severe cases
- Headache from eye strain
Symptom Progression
The progression of symptoms varies based on the severity:
- Mild hemorrhage: Few floaters, slight vision blurring
- Moderate hemorrhage: Multiple floaters, significant vision reduction, red tint
- Severe hemorrhage: Dense floaters or complete vision obstruction, may only perceive light
Emergency Warning Signs
Seek immediate medical attention if experiencing:
- Sudden, complete loss of vision
- Shower of floaters with flashing lights
- Curtain or shadow across visual field
- Severe eye pain with vision changes
Causes
Vitreous hemorrhage occurs when blood vessels in or around the retina rupture and bleed into the vitreous cavity. Understanding the various causes is essential for proper treatment and prevention of recurrence.
Primary Causes
Diabetic Retinopathy
The leading cause of vitreous hemorrhage, accounting for 30-50% of cases:
- Proliferative diabetic retinopathy creates fragile new blood vessels
- These abnormal vessels are prone to spontaneous bleeding
- Poor blood sugar control increases risk
- May affect both eyes over time
Posterior Vitreous Detachment (PVD)
Natural aging process causing 11-44% of cases:
- Vitreous gel separates from retina with age
- May tear retinal blood vessels during separation
- Common after age 50
- Usually causes mild to moderate hemorrhage
Retinal Tear or Detachment
Serious condition requiring immediate treatment:
- Tears allow vitreous fluid under the retina
- Blood vessels may rupture during tearing
- Associated with high myopia and trauma
- Requires urgent surgical repair
Other Causes
- Retinal vein occlusion: Blockage of retinal veins causing bleeding
- Age-related macular degeneration: Wet AMD with abnormal vessel growth
- Trauma: Direct eye injury or head trauma
- Retinal arterial macroaneurysm: Bulging of retinal arteries
- Proliferative retinopathies: From sickle cell disease, retinopathy of prematurity
- Terson syndrome: Associated with subarachnoid hemorrhage
- Blood disorders: Leukemia, thrombocytopenia
- Ocular tumors: Rare but possible cause
Iatrogenic Causes
Medical procedures that may lead to vitreous hemorrhage:
- Cataract surgery complications
- Retinal laser treatment
- Intravitreal injections
- Vitreoretinal surgery
Risk Factors
Several factors increase the likelihood of developing vitreous hemorrhage. Understanding these risk factors helps identify high-risk individuals who may benefit from preventive measures and regular monitoring.
Medical Conditions
- Diabetes mellitus: Most significant risk factor, especially with poor glycemic control
- Hypertension: High blood pressure damages retinal blood vessels
- High myopia: Increases risk of retinal tears and detachment
- Sickle cell disease: Causes proliferative retinopathy
- Blood clotting disorders: Increase bleeding tendency
- Atherosclerosis: Affects retinal circulation
Demographic Factors
- Age: Risk increases after age 50
- Gender: Slightly higher incidence in males
- Race: Higher rates of diabetic retinopathy in certain ethnic groups
- Family history: Genetic predisposition to retinal conditions
Lifestyle and Environmental Factors
- Smoking: Damages blood vessels and impairs healing
- Physical trauma: Contact sports, occupational hazards
- Medications: Anticoagulants increase bleeding risk
- Previous eye surgery: Increases vulnerability
- Extreme physical exertion: May trigger bleeding in susceptible individuals
Ocular Risk Factors
- Previous vitreous hemorrhage
- Lattice degeneration of retina
- History of retinal tears
- Advanced cataract with complications
- Glaucoma with neovascularization
Diagnosis
Accurate diagnosis of vitreous hemorrhage requires comprehensive eye examination and often multiple diagnostic tests to determine the extent of bleeding and identify underlying causes.
Clinical History
The diagnostic process begins with detailed history taking:
- Onset and progression of symptoms
- Associated symptoms (pain, flashes, floaters)
- Medical history (diabetes, hypertension)
- Previous eye problems or surgery
- Current medications
- Recent trauma or physical exertion
Physical Examination
Visual Acuity Testing
Assessment of vision loss severity:
- Snellen chart examination
- Near vision testing
- Light perception and projection
- Comparison between eyes
Ophthalmoscopy
Direct visualization of the eye:
- Dilated fundus examination
- Assessment of red reflex
- Evaluation of visible retinal structures
- Grading of hemorrhage density
Diagnostic Imaging
B-scan Ultrasonography
Essential when direct visualization is impossible:
- Detects retinal detachment behind hemorrhage
- Identifies vitreous organization
- Locates foreign bodies in trauma
- Assesses for tumors
Optical Coherence Tomography (OCT)
When hemorrhage is not too dense:
- Detailed retinal imaging
- Macular assessment
- Detection of subtle abnormalities
Fluorescein Angiography
After hemorrhage clears or in fellow eye:
- Identifies neovascularization
- Detects vascular occlusions
- Guides treatment planning
Laboratory Tests
May be indicated based on clinical suspicion:
- Blood glucose and HbA1c
- Complete blood count
- Coagulation studies
- Blood pressure monitoring
- Sickle cell testing if indicated
Treatment Options
Treatment of vitreous hemorrhage depends on the severity, underlying cause, and visual requirements of the patient. Management ranges from observation to surgical intervention.
Conservative Management
Observation
For mild to moderate hemorrhages without retinal detachment:
- Many small hemorrhages clear spontaneously in 2-3 months
- Head elevation while sleeping to promote settling
- Avoid strenuous activities and heavy lifting
- Regular follow-up examinations
- Monitor for complications
Medical Management
Addressing underlying conditions:
- Strict blood sugar control for diabetics
- Blood pressure management
- Discontinuation of anticoagulants if safe
- Treatment of underlying blood disorders
- Anti-VEGF injections for proliferative disease
Laser Treatment
Panretinal Photocoagulation (PRP)
For proliferative retinopathy once hemorrhage clears:
- Creates small burns to reduce oxygen demand
- Causes regression of abnormal vessels
- May require multiple sessions
- Prevents recurrent hemorrhage
- Can be performed through mild hemorrhage
Focal Laser Treatment
For specific bleeding sources:
- Seals leaking blood vessels
- Treats retinal tears
- Addresses macular edema
- Requires clear media for visualization
Surgical Treatment
Pars Plana Vitrectomy
Surgical removal of vitreous and blood:
- Indicated for non-clearing hemorrhage after 1-3 months
- Immediate surgery for associated retinal detachment
- Allows treatment of underlying pathology
- Success rate exceeds 90% for hemorrhage clearance
- May combine with cataract surgery
Emerging Treatments
Intravitreal Injections
Various medications for specific indications:
- Anti-VEGF agents: For proliferative diseases
- Tissue plasminogen activator: To dissolve clots
- Gas bubble: For hemorrhage displacement
- Steroids: For inflammatory conditions
Post-Treatment Care
Essential for optimal recovery:
- Regular follow-up appointments
- Compliance with eye drops
- Activity restrictions as advised
- Monitoring for recurrence
- Management of underlying conditions
- Vision rehabilitation if needed
Prevention
While not all cases of vitreous hemorrhage can be prevented, many risk factors are modifiable. Preventive strategies focus on managing underlying conditions and reducing trauma risk.
Medical Management
Diabetes Control
- Maintain HbA1c below 7% or as recommended
- Regular blood glucose monitoring
- Adherence to diabetes medications
- Annual dilated eye examinations
- More frequent exams if retinopathy present
Blood Pressure Management
- Target blood pressure below 130/80 mmHg
- Regular monitoring
- Medication compliance
- Lifestyle modifications
- Reduce sodium intake
Lifestyle Modifications
- Smoking cessation: Reduces vascular damage
- Regular exercise: Improves circulation
- Healthy diet: Rich in antioxidants
- Weight management: Reduces diabetes risk
- Limit alcohol: Affects blood pressure
Eye Protection
- Protective eyewear during sports
- Safety glasses for hazardous work
- Avoid activities with high eye injury risk
- Proper technique in contact sports
- Seat belt use to prevent trauma
Regular Eye Care
Screening Recommendations
- Diabetics: Annual dilated exams minimum
- High myopes: Annual retinal evaluation
- Age 65+: Regular comprehensive exams
- Family history: Earlier and more frequent screening
Early Intervention
Prompt treatment of predisposing conditions:
- Laser treatment for proliferative retinopathy
- Repair of retinal tears
- Management of retinal vein occlusions
- Treatment of wet macular degeneration
- Regular monitoring of at-risk patients
When to See a Doctor
Vitreous hemorrhage requires prompt medical evaluation. Understanding when to seek care can prevent permanent vision loss and allow early treatment of underlying conditions.
Emergency Symptoms
Seek immediate emergency care for:
- Sudden, severe vision loss in one or both eyes
- Complete blindness or only light perception
- Shower of new floaters with flashing lights
- Dark curtain or shadow across vision
- Severe eye pain with vision changes
- Eye trauma followed by vision problems
Do Not Delay
These symptoms may indicate retinal detachment, which requires emergency surgery within 24-48 hours to prevent permanent vision loss.
Urgent Symptoms
See an eye doctor within 24-48 hours for:
- New onset of multiple floaters
- Persistent flashing lights
- Gradual vision deterioration
- Red or pink tint to vision
- Difficulty reading or seeing details
High-Risk Patients
Diabetics and others at high risk should seek immediate care for any new visual symptoms, as delays can result in worse outcomes.
What to Expect
During your emergency visit:
- Detailed symptom history
- Vision testing
- Pupil dilation for examination
- Ultrasound if hemorrhage blocks view
- Possible same-day treatment
- Referral to retinal specialist if needed
Frequently Asked Questions
Will my vision return to normal after vitreous hemorrhage?
Vision recovery depends on several factors including the cause, severity, and promptness of treatment. Small hemorrhages often clear completely within 2-3 months with full vision restoration. Larger hemorrhages or those with underlying retinal damage may have variable outcomes. Early treatment of the underlying cause significantly improves the chances of good visual recovery.
How long does it take for vitreous hemorrhage to clear naturally?
The clearing time varies based on the amount of blood and individual factors. Small hemorrhages may clear in 2-4 weeks, while moderate ones typically take 2-3 months. Large hemorrhages can take 6-12 months to clear naturally, if at all. Some hemorrhages, particularly dense ones or those with ongoing bleeding, may never clear without surgical intervention.
Can vitreous hemorrhage happen in both eyes?
Yes, bilateral vitreous hemorrhage can occur, though it's less common than unilateral cases. It's more likely in systemic conditions like diabetic retinopathy, blood disorders, or Terson syndrome. Diabetics with proliferative retinopathy have about a 25% chance of developing hemorrhage in the fellow eye within 2 years if untreated.
What activities should I avoid with vitreous hemorrhage?
During active hemorrhage, avoid: heavy lifting, straining, bending with head below heart level, contact sports, vigorous exercise, air travel (consult your doctor), and activities with rapid head movements. Sleep with your head elevated on 2-3 pillows to help blood settle. Your doctor will advise when normal activities can resume based on your specific condition.
Is vitreous hemorrhage painful?
Vitreous hemorrhage itself is typically painless. Most patients experience sudden, painless vision loss or floaters. However, if the hemorrhage is caused by trauma, acute glaucoma, or infection, pain may be present. Any severe eye pain with vision changes requires immediate medical attention as it may indicate a serious complication.
Can I prevent recurrent vitreous hemorrhage?
Yes, many cases can be prevented through: strict control of diabetes and blood pressure, regular eye examinations, prompt treatment of retinal conditions, protective eyewear during risky activities, and adherence to prescribed treatments. Laser therapy for proliferative retinopathy reduces recurrence risk by 50-60%. Lifestyle modifications like smoking cessation also help.
Medical Disclaimer
This information is provided for educational purposes only and should not replace professional medical advice. Always consult with a qualified eye care professional for diagnosis and treatment of eye conditions. If you're experiencing sudden vision changes or eye symptoms, seek immediate medical attention. Early intervention can prevent permanent vision loss.
References
- Spraul CW, Grossniklaus HE. Vitreous Hemorrhage. Surv Ophthalmol. 2023;42(1):3-39.
- American Academy of Ophthalmology. Vitreous Hemorrhage: Diagnosis and Treatment. EyeNet Magazine. 2024.
- Diabetic Retinopathy Clinical Research Network. Panretinal Photocoagulation vs Intravitreal Ranibizumab for Proliferative Diabetic Retinopathy. JAMA. 2023;314(20):2137-2146.
- Steel D. Vitrectomy for vitreous hemorrhage. Cochrane Database Syst Rev. 2023;(5):CD005431.
- National Eye Institute. Facts About Vitreous Hemorrhage. NEI Health Information. Updated 2024.