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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

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Approach_toa_caseofVitreous _Hemorrhage.ppt

  • 1. Approach to a case of vitreous haemorrhage Sandeep Saxena MS, FRCSEd Professor Department of Ophthalmology KGMU, Lucknow September 27, 2014
  • 2. 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
  • 3. • 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)
  • 4. • Vitreous degeneration - Syneresis -Vitreous liquefaction, fibril aggregation and condensation -Associated with floaters -Caused by myopia, senescence, trauma, inflammation, etc. - Posterior vitreous detachment
  • 5. 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
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. • Complications like vitreous liquefaction, degeneration and ghost cell glaucoma may occur • Fibrous proliferation may develop which may be complicated by tractional retinal detachment
  • 11. 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
  • 12. • 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