Approach to a case of vitreous haemorrhage Sandeep Saxena MS, FRCSEd Professor Department of Ophthalmology KGMU, Lucknow September 27, 2014

Vitreous Humor Inert, transparent, jelly-like structure Normal volume- 4ml Composed of a network of collagen fibrils interspersed with hyaluronic acid molecules Can be divided into cortex and nucleus Attachments - Vitreous base-strongest adherance about 4mm across the orra serrata -Around margins of optic disc, foveal region, along retinal vessels

Ageing changes- -Dissociation of hyaluronate from collagen fibrils -Pooling of hyaluronate -Fibril degeneration and decreased elasticity -Drainage of hyaluronate into retrovitreal space (posterior vitreous detachment)

Vitreous degeneration - Syneresis -Vitreous liquefaction, fibril aggregation and condensation -Associated with floaters -Caused by myopia, senescence, trauma, inflammation, etc. - Posterior vitreous detachment

Vitreous Haemorrhage  Causes Proliferative retinopathies- -Diabetes mellitus -Retinal vein occlusion -Retinopathy of prematurity -Eale’s disease Rhegmatogenous retinal detachment Posterior vitreous detachment Trauma Systemic – Bleeding disorders

Pathophysiology Retinal ischemia causing release of angiogenic vasoactive factors (like VEGF) Tear in retinal vasculature due to break in the retina or detachment of posterior vitreous Subretinal bleeding with secondary extension into the vitreous cavity- less common

Clinical features Symptoms- -Sudden appearance of floaters - small vitreous haemorrhage -Sudden painless loss of vision- large vitreous haemorrhage Signs- - No red glow on distant direct ophthalmoscopy - Blood in vitreous cavity on indirect ophthalmoscopy

Patient workup Slit lamp examination of the eye Pupil dilatation and fundus examination B scan ultrasound for posterior segment evaluation Blood tests to check for specific causes such as diabetes CT scan may be required in some cases to check for injury around the eye

Fate of vitreous haemorrhage Complete resolution may occur within 4-8 weeks without organisation with vitreous Organisation of haemorrhage with formation of a yellowish-white debris occurs in persistent or recurrent bleeding

Complications like vitreous liquefaction, degeneration and ghost cell glaucoma may occur Fibrous proliferation may develop which may be complicated by tractional retinal detachment

Management Conservative management consists of bed rest with elevation of patient’s head end to facilitate settlement of blood Treatment of cause- Once the blood settles down, indirect ophthalmoscopy should be done to locate and further manage the cause of haemorrhage

Pars plana vitrectomy may be attempted to clear the vitreous, if the haemorrhage does not get absorbed in 3 months Early vitrectomy followed by laser photocoagulation may be required in cases associated with retinal detachment

Thank you