Vitreous hemorrhage - Causes, Treatment & When to See a Doctor

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What is Vitreous Hemorrhage?

A vitreous hemorrhage (VH) is the presence of blood within the vitreous cavity – the clear, gel‑like substance that fills most of the eye behind the lens and in front of the retina. The vitreous normally allows light to pass unimpeded to the retina, so when blood leaks into this space it can scatter light, causing sudden or gradual loss of vision, floaters, or a “shower” of dark spots. While a small bleed may clear on its own, larger or recurrent hemorrhages can threaten sight and often signal an underlying ocular or systemic problem.<sup>1</sup>

Common Causes

Vitreous hemorrhage can arise from many different ocular conditions, trauma, or systemic diseases. The most frequent culprits include:

• Proliferative diabetic retinopathy (PDR) – New, fragile blood vessels grow on the retinal surface and can rupture into the vitreous.
• Retinal tears or detachments – A break in the retina allows fluid and blood to seep into the vitreous.
• Posterior vitreous detachment (PVD) with retinal tear – As the vitreous pulls away from the retina, it can create a tear that bleeds.
• Ocular trauma – Blunt or penetrating injuries can damage retinal vessels directly.
• Neovascular age‑related macular degeneration (nAMD) – Abnormal vessels under the macula may bleed.
• Retinal vein occlusion (RVO) – Blocked veins raise venous pressure, leading to hemorrhage.
• Retinoblastoma or other intra‑ocular tumors – Tumor vessels are prone to rupture.
• Sickle cell retinopathy – Vaso‑occlusive events cause peripheral retinal ischemia and neovascular bleeding.
• Blood disorders – Conditions such as leukemia, severe thrombocytopenia, or clotting factor deficiencies can predispose to spontaneous intra‑ocular bleeding.
• Infectious or inflammatory diseases – Endophthalmitis, uveitis, or toxoplasmosis may disrupt retinal vasculature.

Associated Symptoms

Patients with a vitreous hemorrhage often notice one or more of the following:

• Sudden onset of “floaters” that look like dark specks, cobwebs, or a veil covering part of the visual field.
• Partial or complete loss of vision in the affected eye, ranging from mild blurring to total blackout.
• Redness or mild pain if the hemorrhage is accompanied by inflammation.
• Peripheral “shadow” or curtain‑like effect – especially if a retinal tear or detachment is present.
• Flashing lights (photopsia) preceding or concurrent with the bleed, often indicating traction on the retina.

When to See a Doctor

Because a vitreous hemorrhage can be a sign of a sight‑threatening problem, prompt evaluation is essential. Seek ophthalmic care if you experience:

• Sudden appearance of numerous floaters or a “shower” of blood‑colored spots.
• Any loss of vision, even if it seems temporary.
• Flashes of light, especially when associated with a new floaters.
• Eye pain, redness, or discharge.
• History of diabetes, recent eye trauma, or known retinal disease.

If any of these symptoms occur, arrange an eye‑clinic or emergency‑room visit within 24 hours.

Diagnosis

Ophthalmologists use a combination of history, visual‑function testing, and imaging to confirm a vitreous hemorrhage and uncover its cause.

1. Clinical Examination

• Visual acuity test – Determines the degree of vision loss.
• Slit‑lamp biomicroscopy – Allows close inspection of the anterior segment and peripheral vitreous.
• Fundus examination – Direct or indirect ophthalmoscopy evaluates the retina; however, heavy bleeding may obscure the view.

2. Imaging Studies

• Ultrasound B‑scan – Provides a cross‑sectional image of the eye; essential when the view of the retina is blocked by blood.
• Optical coherence tomography (OCT) – Offers high‑resolution images of the macula and peripheral retina if enough light penetrates the hemorrhage.
• Fluorescein angiography (FA) – Highlights abnormal retinal vessels (used after the bleed clears enough to see the retina).

3. Laboratory Work‑up (selected cases)

When a systemic cause is suspected, blood tests may include a complete blood count, coagulation profile, HbA1c, and inflammatory markers.

Treatment Options

Treatment is directed at two goals: (1) clearing the hemorrhage to restore vision, and (2) addressing the underlying condition to prevent recurrence.

1. Observation

Small, non‑dense hemorrhages often resolve spontaneously over weeks to months as the vitreous naturally clears the blood. During this period, patients are advised to avoid strenuous activity and keep follow‑up appointments.

2. Medical Management

• Intravitreal anti‑VEGF injections – Used for bleeding due to neovascular diseases such as proliferative diabetic retinopathy or neovascular AMD. Agents (e.g., ranibizumab, aflibercept) reduce new vessel growth and help hemorrhage re‑absorption.<sup>2</sup>
• Systemic control of diabetes or hypertension – Tight glycemic and blood‑pressure control slows progression of diabetic retinopathy.
• Coagulopathy correction – If the patient has a bleeding disorder, reversal of anticoagulation or platelet transfusion may be indicated.

3. Surgical Intervention

When the hemorrhage is dense, persistent, or associated with retinal tears/detachment, surgery is often required.

• Pars plana vitrectomy (PPV) – The gold‑standard procedure. Small instruments are inserted through the sclera to remove the blood‑filled vitreous, repair retinal tears, and apply laser photocoagulation or silicone oil tamponade when needed.
• Scleral buckle – Occasionally combined with vitrectomy for retinal detachment repair.
• Laser photocoagulation – Applied intra‑operatively or after vitrectomy to seal retinal tears or treat ischemic retina.

Recovery after vitrectomy usually takes 4–6 weeks; most patients regain useful vision if the retina remains attached and macular damage is limited.

4. Home Care & Supportive Measures

• Rest in a semi‑upright position to promote settling of blood away from the visual axis.
• Avoid heavy lifting, vigorous exercise, or activities that increase intra‑ocular pressure for at least 1‑2 weeks post‑procedure.
• Use prescribed eye drops (e.g., antibiotics, steroids) exactly as directed.
• Maintain a diabetic eye‑care schedule – at least yearly dilated exams, more often if you have proliferative disease.

Prevention Tips

While some causes (e.g., trauma) are avoidable, many vitreous hemorrhages stem from chronic eye disease. Preventive measures focus on risk‑factor control and regular eye monitoring.

• Control diabetes meticulously – Aim for HbA1c < 7 % (or as individualized by your provider). Use regular retinal screening every 6‑12 months.<sup>3</sup>
• Manage blood pressure – Hypertension accelerates retinal vessel damage.
• Protect your eyes – Wear appropriate safety glasses during sports, woodworking, or any activity with a risk of impact.
• Avoid smoking – Smoking worsens vascular disease, including diabetic retinopathy.
• Regular ophthalmic exams – Early detection of retinal tears, neovascularization, or macular degeneration allows timely laser or anti‑VEGF therapy.
• Adhere to anticoagulant therapy instructions – If you take warfarin, DOACs, or antiplatelet agents, have your INR or relevant labs checked as recommended.
• Prompt treatment of eye infections or inflammation – Reduces the risk of secondary bleeding.

Emergency Warning Signs

Key Take‑aways

Vitreous hemorrhage is a potentially serious eye condition that typically reflects underlying retinal disease, trauma, or systemic bleeding disorders. Prompt recognition, thorough evaluation (especially with ultrasound when the view is obscured), and timely treatment—ranging from observation to vitrectomy—can preserve vision. Long‑term prevention hinges on controlling systemic risk factors, protecting the eyes from injury, and maintaining regular retinal screenings. When sudden visual changes occur, do not wait—seek professional care right away.

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References:

1. Mayo Clinic. Vitreous hemorrhage. Accessed April 2024.
2. American Academy of Ophthalmology. Anti‑VEGF therapy for diabetic retinopathy. Accessed April 2024.
3. National Institute of Diabetes and Digestive and Kidney Diseases. Diabetic eye disease. Accessed April 2024.
4. World Health Organization. Global report on age‑related macular degeneration. 2023.
5. Cleveland Clinic. Vitreous hemorrhage: Symptoms, causes, and treatment. Accessed April 2024.

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