Retinal Hemorrhage: Symptoms, Types, Causes and Treatment

Retinal hemorrhage is a potentially sight-threatening condition in which bleeding occurs within or around the retina—the light-sensitive tissue at the back of the eye. While its causes and outcomes can vary greatly, early recognition and appropriate treatment are essential to preserve vision and address any underlying health concerns. This article provides a comprehensive overview of retinal hemorrhage, including its symptoms, types, causes, and the most current treatment strategies, drawing on up-to-date research and clinical literature.

Symptoms of Retinal Hemorrhage

Retinal hemorrhages can be silent or present with a spectrum of symptoms. Because the retina is responsible for capturing visual information, any bleeding can disrupt vision, sometimes in subtle ways. Recognizing these symptoms is crucial for prompt diagnosis and intervention.

Symptom	Description	Severity/Onset	Source(s)
Vision Loss	Sudden or gradual decline in vision	Mild to severe	2 12 13
Blurred Vision	Hazy or distorted vision	Acute or progressive	2 12
Floaters	Dark spots or lines moving in vision	Sudden	2 4 12
Visual Field Defects	Partial loss of visual field	Variable	2 11 12
Eye Pain	Discomfort (less common)	Sometimes	12

Table 1: Key Symptoms

Understanding the Symptoms

Vision Loss and Blurred Vision

• Sudden vision loss is a hallmark of significant retinal hemorrhage, especially if blood accumulates near or over the macula (the central area responsible for sharp vision) 2 12 13.
• Blurring of vision can be mild if the hemorrhage is small or peripheral, but becomes more pronounced when the central retina is involved.

Floaters and Visual Disturbances

• Patients often describe floaters—dark, mobile spots or cobweb-like lines—when blood leaks into the vitreous or preretinal space 2 4 12.
• Visual field defects may occur if a larger area of the retina is affected, resulting in shadows or blind spots 2 11 12.

Eye Pain and Other Symptoms

• Pain is uncommon but may accompany traumatic or severe hemorrhages, especially if there's increased intraocular pressure or concurrent injury 12.
• In some cases, especially with small or peripheral hemorrhages, no symptoms are noticed until an eye exam reveals the bleeding.

When to Seek Medical Attention

• Any sudden change in vision, appearance of floaters, or visual field loss warrants prompt evaluation by an eye specialist, as early treatment can make a significant difference in outcomes 12 13.

Types of Retinal Hemorrhage

Retinal hemorrhages are classified by their location within or around the retina. Each type has distinct characteristics and implications for both diagnosis and management.

Type	Location in Retina/Surroundings	Typical Appearance	Source(s)
Intraretinal	Within retinal layers	Flame, dot, or blot shapes	2 10
Preretinal/Subhyaloid	Between retina and vitreous	Dome, crescent, or semilunar	2 9
Subretinal	Between retina and RPE*	Irregular red plaques	2 11 12 13
Sub-RPE	Beneath retinal pigment epithelium	Diffuse, linear	2 10
Intravitreal	In vitreous cavity	Diffuse, slow clearing	2 4
Choroidal	In choroid beneath retina	Dark reddish-blue areas	2
Roth’s Spots	White-centered hemorrhages	White center in red spot	2

*RPE: Retinal pigment epithelium

Table 2: Types of Retinal Hemorrhage

Exploring the Types

Intraretinal Hemorrhages

• Flame-shaped hemorrhages: Superficial, following the nerve fiber layer, often bright red and associated with vascular disease.
• Dot and blot hemorrhages: Deeper in the retina, round or irregular, commonly linked to conditions like diabetic retinopathy 2 10.

Preretinal (Subhyaloid) Hemorrhages

• Located between the retina and the vitreous, these appear as dome-shaped or crescentic pools of blood that may obscure underlying vessels. They can shift with gravity and head position 2 9.
• Premacular hemorrhages—a subtype—can cause sudden, dramatic vision loss if they cover the macula 9.

Subretinal and Sub-RPE Hemorrhages

• Subretinal hemorrhages: Blood collects beneath the neurosensory retina, often appearing as irregular red plaques; commonly due to trauma, age-related macular degeneration (AMD), or vascular occlusion 2 11 12 13.
• Sub-RPE hemorrhages: Blood under the RPE, usually associated with ruptures of Bruch's membrane due to trauma or hereditary disorders 2 10.

Intravitreal and Choroidal Hemorrhages

• Intravitreal hemorrhage: Blood in the vitreous cavity, less common in children, can lead to floaters and vision loss. It tends to resolve slowly 2 4.
• Choroidal hemorrhage: Deep bleeding beneath the retina, seen as dark reddish-blue patches; typically resolves without lasting damage 2.

Roth’s Spots

• White-centered hemorrhages, resulting from focal ischemia or deposits (e.g., platelets, infectious material), seen in various systemic conditions 2.

Causes of Retinal Hemorrhage

Retinal hemorrhage can stem from a wide range of underlying problems, from trauma to systemic disease. Understanding the causes is pivotal for effective management and for identifying any serious or life-threatening underlying conditions.

Cause	Mechanism/Trigger	Typical Patient Group	Source(s)
Trauma (including AHT*)	Acceleration-deceleration, impact	Infants, young children	1 3 5 6 8
Vascular Disease	Vessel leakage, microaneurysms	Adults (diabetes, hypertension)	2 4 10 13
Ocular Surgery/Procedures	Iatrogenic, post-surgical bleeding	All ages	2 11
Blood Disorders	Coagulopathy, platelet issues	Variable	2 11
High Altitude	Hypoxia-induced vessel rupture	Climbers/athletes	4
Age-related Changes	Fragile vessels, AMD	Elderly	13
Others (Valsalva, etc.)	Sudden pressure changes/straining	All ages	9 12
Vaccines	Not causative	Children	7

*AHT: Abusive Head Trauma

Table 3: Main Causes of Retinal Hemorrhage

Detailed Examination of Causes

Traumatic Causes

• Abusive Head Trauma (AHT):
  • Includes "shaken baby syndrome;" repetitive acceleration-deceleration forces cause vitreoretinal traction and vascular rupture 1 3 6 8.
  • Retinal hemorrhages in AHT often extend from the posterior pole to the periphery and may be associated with other retinal findings such as folds or retinoschisis 3.
  • Not all retinal hemorrhages in children are due to abuse; accidental trauma can also cause them but typically with different patterns 5.

Vascular and Systemic Disorders

• Diabetic and hypertensive retinopathy:
  • Chronic high blood sugar or pressure damages small retinal vessels, leading to leakage and bleeding 2 4 10 13.
  • Retinal macroaneurysms can rupture, causing sudden, profound hemorrhages 10.
• Blood disorders:
  • Coagulation defects and platelet abnormalities increase bleeding risk, resulting in spontaneous retinal hemorrhages 2 11.

Ocular and Environmental Factors

• Ocular surgery:
  • Procedures such as laser or vitrectomy may inadvertently cause bleeding 2 11.
• High altitude:
  • Rapid ascent and hypoxia can stress retinal vessels, particularly in climbers 4.

Age-Related and Other Causes

• AMD (Age-related macular degeneration):
  • Fragile neovascular membranes can bleed, especially under the retina (subretinal hemorrhage) 13.
• Valsalva retinopathy:
  • Sudden increases in intrathoracic pressure (e.g., heavy lifting, coughing) cause small vessel rupture 9 12.

Debunked Theories

• Vaccination:
  • Large studies show no association between vaccines and retinal hemorrhage, countering claims in some legal contexts 7.
  • When retinal hemorrhage is observed in a child, especially without other disease, abuse or trauma must be considered 7.

Treatment of Retinal Hemorrhage

Treatment of retinal hemorrhage depends on its type, severity, underlying cause, and the patient’s overall health. Advances in imaging and therapy have enabled more personalized, effective interventions, aiming to preserve vision and prevent complications.

Treatment Option	Best For	Key Considerations	Source(s)
Observation	Small, peripheral hemorrhages	Spontaneous resolution	9 10 12 13
Vitrectomy	Dense vitreous/preretinal bleeds	Invasive, quick clearing	2 9 10 12
Nd:YAG Laser	Premacular/preretinal hemorrhage	Minimally invasive, rapid	9
Intravitreal Gas	Subretinal hemorrhage	Non-surgical, less invasive	10 12
tPA Injection	Submacular hemorrhage	Clot dissolution, often combined with gas	12
Anti-VEGF Therapy	Neovascular/AMD-related bleeds	Reduces new vessel growth	12 13
Address Underlying Cause	All types	Essential for recurrence prevention	2 4 11

Table 4: Main Treatment Approaches

Deeper Dive into Treatment Strategies

Observation and Conservative Management

• Small, non-central hemorrhages often resolve without intervention; regular monitoring with fundus exams is advised 9 10 12 13.
• Children with intravitreal bleeds may need early vitrectomy to prevent amblyopia (lazy eye) 2.

Surgical and Minimally Invasive Techniques

• Pars plana vitrectomy:

  • Removes blood from the vitreous or preretinal space, rapidly restoring vision but with surgical risks 2 9 10 12.
  • Preferred in dense, non-resolving hemorrhages or when rapid visual rehabilitation is needed.

• Nd:YAG laser membranotomy:

  • For dense premacular hemorrhage, a focused laser creates an opening in the membrane, allowing blood to drain into the vitreous for faster clearing 9.

• Intravitreal gas injection:

  • Gas bubble (often with patient in a prone position) displaces subretinal blood away from the macula 10 12.
  • Sometimes combined with tPA (tissue plasminogen activator) to liquefy and mobilize the clot 12.

Pharmacologic Interventions

• Tissue plasminogen activator (tPA):

  • Breaks down clots; used intravitreally or subretinally, often in combination with gas for submacular hemorrhage 12.
  • Less invasive than surgery and effective in selected cases.

• Anti-VEGF agents:

  • Particularly effective in AMD-related hemorrhages; they inhibit abnormal vessel growth and reduce the risk of further bleeding 12 13.
  • May be used alone or as adjunctive therapy.

Treating the Underlying Cause

• Systemic management:
  • Control of diabetes, hypertension, and underlying systemic or blood disorders is crucial to prevent recurrence 2 4 11.
• In trauma or abuse cases:
  • Multidisciplinary intervention including child protection or neurosurgical care may be required 1 3 6 8.

Emerging and Experimental Therapies

• Cell death pathway modulation:
  • Early research suggests that targeting specific cell death mechanisms (e.g., apoptosis, ferroptosis) in subretinal hemorrhage could protect retinal cells and improve outcomes 11.
• Further studies needed:
  • No universally accepted “gold standard” treatment yet, especially for complex or chronic cases 13.

Conclusion

Retinal hemorrhage is a multifaceted condition with a variety of causes, presentations, and treatment options. Early recognition and tailored therapy are vital for preserving vision and addressing any underlying health issues.

Key Takeaways:

• Retinal hemorrhage can cause vision loss, floaters, and visual field defects, but sometimes presents silently 2 12 13.
• Types include intraretinal, preretinal, subretinal, sub-RPE, intravitreal, and choroidal hemorrhages, each with distinct features and implications 2 9 10 11 13.
• Causes range from trauma (notably abusive head trauma in children) to vascular diseases, blood disorders, surgery, and age-related changes; vaccines do not cause retinal hemorrhage 1 3 5 6 8 10 13 7.
• Treatment must be individualized and may include observation, vitrectomy, laser, gas injection, tPA, anti-VEGF agents, and management of underlying diseases 9 10 12 13.
• Continued research and a multidisciplinary approach are needed to optimize outcomes in complex or severe cases 11 13.

If you or someone you know experiences sudden changes in vision, it is essential to seek prompt ophthalmologic evaluation to ensure the best possible outcome.