03 Mar 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
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!
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.
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.