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Vitreous Hemorrhage | A Dilemma

Here's a real case I faced just last week. A patient with loss of vision from bleeding in the vitreous. I never know if I should operate...or not.

Vitreous Hemorrhage presents dilemma in treatment | Randall Wong, M.D., Retina Specialist, Fairfax, VirginiaOn Thursday morning, I met a 75 YOM (year old male) who had lost vision just the day before.  He was referred to me for evaluation of a dense vitreous hemorrhage in his left eye.  He is healthy and never had any eye problems before.

This is one of the more difficult patient situations for me to manage.  This is a case of a dense vitreous hemorrhage in a patient without diabetes.

The situation is challenging for several reasons.  The hemorrhage happens suddenly and without warning.  A vitreous hemorrhage is painless, yet can produce profound vision loss depending upon the amount of bleeding.   Up to this moment, most patients have enjoyed excellent vision.   I don’t blame patients for being anxious.

The situation is more complex because I can’t make a definitive diagnosis as to the actual cause of the vitreous bleeding.  Blood in the vitreous causes immediate loss of vision because it blocks the light from hitting the retina.

Patients can’t see “out” and I can’t see “in.”

Causes of Vitreous Hemorrhage

There are only 2 likely causes of the vitreous hemorrhage in this scenario.   Bleeding with a retinal tear or bleeding without a retinal tear.

Remember that retinal tears can cause retinal detachments.  Retinal detachments are potentially blinding and will require surgery to repair.

Therefore, an undiagnosed retinal tear has the potential for developing a retinal detachment at any time.

Appropriate treatment for a retinal tear with vitreous hemorrhage might be to operate (vitrectomy) and remove the blood.  Removal of the blood allows excellent visualization of the retina and the tear.

Appropriate treatment for a vitreous hemorrhage without a tear is to wait – do nothing.

After performing an ultrasound (B-Scan ultrasound), I was able to determine that the retina was not detached.  Therefore,  there was no immediate cause for concern.

Vitrectomy for Vitreous Hemorrhage, or NOT?

Again, the dilemma is that I don’t know for sure if there is a retinal tear.  I only know that there is no retinal detachment and there may or may not be a retinal tear.

The might absorb over the next few weeks allowing better and more definitive examination, or it might not.  There’s about a 50/50 chance the blood will absorb.  It may take weeks to go away if at all.

Meanwhile, a retinal detachment could ensue.

Advantages of waiting are avoidance of an operation and its possible complications.

Disadvantages of waiting:

  • retinal detachment develops (potential for permanent loss of vision)
  • possibility of emergency surgery (never ideal)
  • surgery may be needed anyway (blood doesn’t absorb)
  • frequent return office visits

Advantage to Vitrectomy

  • definitive treatment
  • faster restoration of vision
  •  likely avoid retinal detachment

Risks of Vitrectomy

  • blinding infection (endophthalmitis – chance is less than cataract surgery)
  • creating a retinal detachment (about 2% chance)

After balancing all his options, my patient chose to operate.