Diabetic retinopathy Uncategorized

Vitreous Hemorrhage in a Patient with Diabetes

This a vitreous hemorrhage.  The patient has a 30+ year history of Type 1 diabetes, has had cataract surgery in both eyes and never had laser or vitreo-retinal surgery for treatment of her diabetic retinopathy.

Essentially, she has been doing very well.  I see her at least twice a year to insure there is no diabetic macular edema and no sign of proliferative diabetic retinopathy.

She has been complaining of a “pixelated” change to the vision of the left eye.  (Honestly, as I told her, I have no idea what “pixelated” means.)

Dilated Eye Examination

Her examination started off normally.  The essential information is as follows;

61 Year Old Female
Bilateral Cataract Surgery
Last Recorded A1C: 8.0
AM Sugar:  90

Vision:  20/20 OD (Right Eye)
20/25 OS (Left Eye)

IOP:  17 OD
20 OS

Every patient gets their pupils dilated so I can examine the retina.  Examination of the retina is paramount in patients with diabetes.

Of significance is that her vision was excellent!

Vitreous Hemorrhage

After dilating her pupils, I was able to diagnose a vitreous hemorrhage.  This is the cause for her “pixelated” vision.  For teaching purposes:

  • This is a photograph of the left retina
  • The scalloped areas are “boat hemorrhages” formed by blood trapped between the retina and the posterior vitreous.  Blood is trapped in a “pocket” between the surface of the retina and the posterior vitreous
  • The top areas are horizontal and “level” due to the effect of gravity – hence,  the “boat”
  • In the larger hemorrhage, notice that the underlying normal retinal blood vessel is hidden – gives you an idea of the actual location of the bleeding

Diagnosis of Proliferative Diabetic Retinopathy

There are many causes of vitreous hemorrhage, but the more likely cause is related to diabetic retinopathy, especially in the absence of a tear in the retina.

While almost every patient with diabetes will develop some early degree of diabetic retinopathy, far fewer develop proliferative diabetic retinopathy.

Proliferative diabetic retinopathy (PDR) is defined as the stage of diabetic retinopathy where abnormal blood vessels, aka “neovascularization,” form somewhere on the retina or elsewhere in the eye.

Neovascular blood vessels are extremely fragile and can bleed easily causing a vitreous hemorrhage.

Sometimes the blood mixes throughout the retina and sometimes, as in this case, the blood remains localized and a nice picture can be obtained.

Vitreous Hemorrhage

In this particular case, my job is to insure that the blood is from the diabetic retinopathy.  As I said above, a retinal tear could also cause a vitreous hemorrhage, so in the absence of a retinal tear or other problem, I can safely observe (i.e. do nothing and simply wait) to see if the hemorrhage resolves on it’s own.  If there were a tear, I would need to treat the tear.

I’ll see this patient back in a few weeks.  The best treatment for this stage of the disease is laser treatment (aka panretinal photocoagulation).

Laser may be attempted in the office if enough of the hemorrhage clears on it’s own.  If not, vitrectomy can remove the blood and laser be performed at the same time.


How I Practice

Vitreous Hemorrhage | A Dilemma

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.

Diabetic retinopathy Treatments

Vitrectomy for Diabetic Retinopathy

Proliferative Diabetic Retinopathy Causes Vitreous Hemorrhage and Diabetic Retinal Detachment

There are two times when a patient needs vitrectomy eye surgery for diabetic retinopathy.  Patients with either a vitreous hemorrhage and/or a diabetic retinal detachment will require a vitrectomy.

Both occur when the diabetic retinopathy has advanced to “proliferative diabetic retinopathy.”  By definition, abnormal blood vessels, called neovascularization have developed somewhere on the retina.

Neither case requires emergency surgery.

What is Proliferative Diabetic Retinopathy

Neovascularization, the abnormal blood vessels, is very fragile.  These delicate blood vessels have grown somewhere inside the eye; usually on the surface of the retina.

There are 3 types of neovascular tissue named based on the location;  neovascularization elsewhere (NVE), neovascularization of the disc (NVD) or neovascularization on the iris (NVI).

Regardless, just remember proliferative diabetic retinopathy, by definition, means abnormal blood vessels are somewhere in the eye!

Vitreous Hemorrhage

At times, these delicate blood vessels may bleed and cause a vitreous hemorrhage.  Blood accumulates inside the eye and blocks the vision.  Patients can’t see “out” and doctors can’t see “in.”

Though the vision loss can be dramatic, and as long as nothing else could have caused the bleeding (i.e. a retinal tear can also cause a vitreous hemorrhage), we usually wait for the blood to clear.  This may take several weeks or longer.

If the blood doesn’t clear, a vitrectomy is needed to remove the blood not absorbed by mother nature.

Diabetic Retinal Detachment

Untreated neovascular tissue may “proliferate” or grow inside the eye.  The tissue may creep along the surface of the retina much the same way ivy grows along the ground…moving slowly from one point to another.

With time, the NV may contract and start to detach the retina.  This type of “traction” retinal detachment is different than retinal detachments sustained by non-diabetic patients.

A retinal detachment caused by diabetes requires vitrectomy surgery to physically cut away or remove the offending tissue pulling up on the retina.

What Does This Mean?

In both cases, laser treatment (panretinal photocoagulation or PRP) is needed to stop the neovascularization.

In the case of a vitreous hemorrhage, if the blood is not absorbed, laser can be performed at the same time as the operation.  If the blood does absorb, laser treatment can be performed in the office.

For patients with a diabetic retinal detachment; however, an operation is often the best and only choice.

With routine eye examination, the neovascular tissue is often detected before bleeding or retinal detachment has occurred.  Treatment can be initiated, operations avoided, and vision preserved!

Diabetic retinopathy

Vitreous Hemorrhage and Diabetes

A vitreous hemorrhage can result in sudden, painless loss of vision.  In patients with diabetes, the cause may be due to either a posterior vitreous detachment (PVD) or proliferative diabetic retinopathy (PDR).  Remember, the proliferative phase of the diabetic retinopathy means that there are areas of neovascularization (abnormal blood vessel proliferation) on the surface of the retina.

In cases where a diabetic patient is diagnosed with a vitreous hemorrhage, my job is to ensure that the cause  is not due to a retinal tear or a retinal detachment.  This can be done by dilating the eye and examining.

You Can’t See Out and I Can’t See In

Sometimes there is so much blood I can not see much or any of the retina.  In these cases, we perform an ultrasound of the eye to make sure the retina is attached.

Sometimes, an ultrasound can locate a retinal tear.  If there is no retinal tear, or retinal detachment, then I am pretty sure that the vitreous hemorrhage is due to the proliferative diabetic retinopathy.

Fragile Vessels

Neovascular vessels are very fragile and may easily break open and bleed.  This may occur with or without straining.  The blood can fill the vitreous cavity causing sudden “loss” of sight.  Vision is “lost”  (not permanently) due to physical blockage of light.

Vitreous Hemorrhage, Proliferative Diabetic Retinopathy, Randall V. Wong, M.D., Fairfax, Virginia.
Vitreous Hemorrhage

Bleeding in the vitreous is benign.  It causes no damage to the vision or to any part of the eye.  On the other hand, as it physically blocks light, patients don’t see well.

Sometimes it is Best to do Nothing

Usually, when I am sure the bleeding is due to diabetic retinopathy, I recommend a period of doing nothing.  We watch and wait.  In doctor lingo, we are observing.

Patients Tire of Not Seeing

After a few weeks, or sometimes longer, we may decide to operate to remove the blood.  Sometimes the blood absorbs on its own and sometimes it doesn’t.  At some point, patients with non-absorbing blood in the eye become tired of the prolonged decreased vision.  A vitrectomy is then scheduled to remove the blood.

What Does This Mean? The sudden loss of vision can be devastating for anyone.  In cases when the loss of vision is due to a vitreous hemorrhage, we need to assess the threat of permanent vision loss due to other causes such as a retinal tear or retinal detachment.

If the eye is stable, that is, we can safely observe, it is sometimes tough to reassure patients that while they just “lost” their vision, the best idea is to do nothing!  Their “lost” vision is temporary.

I often will have a patient return in a short week or two to reassess and help relieve anxiety.

Patients with proliferative diabetic retinopathy, if you remember, will require laser treatment (pan-retinal photocoagulation, aka PRP) to reverse the neovascularization.

While we are waiting for the hemorrhage to clear, at the same time we are mindful that laser treatment is ultimately needed.  If the vitreous hemorrhage clears by itself, laser can be applied in the office.  If we end up operating, the laser can be applied at the same time as the vitrectomy.

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