Vitreous Hemorrhage: Symptoms, Types, Causes and Treatment

Vitreous hemorrhage is a vision-threatening condition resulting from bleeding into the gel-like vitreous cavity of the eye. While it can sometimes resolve on its own, it often signals underlying ocular or systemic disease that requires prompt attention. Recognizing its symptoms, understanding its various types, identifying potential causes, and being aware of both current and emerging treatments can empower patients and clinicians to achieve the best possible outcomes.

Symptoms of Vitreous Hemorrhage

When blood leaks into the vitreous cavity, it disrupts vision in ways that can range from subtle to dramatic. Early recognition of these symptoms is vital, as they often indicate underlying eye disease or injury that may require urgent intervention. Many patients are alarmed by the sudden changes in vision, and timely medical evaluation can be sight-saving.

Symptom	Description	Age/Context	Source(s)
Floaters	Sudden appearance of dark spots or lines	All ages	1 2 4 5
Blurred Vision	Mild to severe reduction in visual clarity	All ages	1 2 3 4
Visual Obscuration	Vision blocked by a red or dark haze	Moderate to severe	3 4 5
Photopsia	Flashes of light	Often with retinal tear	4 5
Strabismus/Nystagmus	Eye misalignment or involuntary movement	Young children	1

Table 1: Key Symptoms

Common Visual Changes

The most frequent symptom is a sudden decrease in visual acuity or the perception of “floaters”—tiny shadows, cobwebs, or dark spots that seem to drift through the visual field. Some people describe seeing a dense red or black curtain, indicating a significant bleed 1 2 3.

Symptom Variation by Age

• Older children and adults tend to notice floaters and blurred vision first.
• Infants and very young children may not verbalize vision changes but could present with strabismus (crossed eyes) or nystagmus (involuntary eye movement) due to sensory deprivation 1.

Associated Symptoms

• Flashes of light (photopsia): Often signal a retinal tear or detachment, a potentially urgent situation 4 5.
• Visual obscuration: When blood fills the vitreous, vision may be blocked almost entirely, sometimes leaving only the ability to perceive light 3.

Clinical Importance

Prompt recognition of these symptoms—especially if they occur suddenly—warrants immediate evaluation by an eye care professional. This is particularly true if accompanied by pain or a history of trauma.

Types of Vitreous Hemorrhage

Not all vitreous hemorrhages are alike. The type of hemorrhage can influence both the treatment approach and the likelihood of visual recovery. Classification is generally based on the underlying cause and clinical presentation.

Type	Key Features	Commonality	Source(s)
Traumatic	Associated with eye injury	Children, adults	1 2 3 5
Spontaneous	No clear trauma; often disease	Adults, some children	1 2 3 5
Unilateral	One eye affected	Most cases	1 2
Bilateral	Both eyes affected	Rare, severe cases	1

Table 2: Types of Vitreous Hemorrhage

Traumatic Vitreous Hemorrhage

• Manifest trauma: Obvious injury, such as blunt force or penetrating trauma, is a leading cause in children and young adults 1.
• Occult trauma: Eye injury may not be apparent at first, but careful history and examination often reveal it 1.

Spontaneous Vitreous Hemorrhage

• Underlying disease: Most spontaneous cases are due to retinal vascular disorders, such as proliferative diabetic retinopathy, retinal vein occlusion, or age-related macular degeneration 2 3 5.
• Other causes: Posterior vitreous detachment, macroaneurysm, or intraocular tumors can also cause spontaneous bleeding 4 5.

Laterality of Hemorrhage

• Unilateral (one eye): The vast majority of cases affect only one eye 1 2.
• Bilateral (both eyes): Rare, most commonly seen in severe trauma (e.g., shaken baby syndrome in children) or systemic diseases 1.

Severity and Extent

• Mild: Small hemorrhages may only cause minor floaters.
• Dense/Severe: Extensive bleeding can fill the vitreous cavity, completely obscuring the retina and causing profound vision loss 3 5.

Causes of Vitreous Hemorrhage

Understanding the underlying cause is critical for effective management, as treatment must address not just the hemorrhage but the root problem. Causes can vary with age, systemic health, and even ethnicity.

Cause	Description	Risk Group/Notes	Source(s)
Proliferative Diabetic Retinopathy (PDR)	Fragile new retinal vessels bleed easily	Commonest cause in adults	2 3 5 7 8
Trauma	Blunt or penetrating injury to the eye	Most common in children	1 2 3 5
Retinal Vein Occlusion	Blockage leads to vessel rupture	Older adults, hypertension	2 3 4 5
Posterior Vitreous Detachment (PVD) & Retinal Tears	Vitreous pulls on retina, causing tears	Elderly, myopic patients	4 5
Age-related Macular Degeneration (AMD)	Abnormal vessels in macula bleed	Older adults	3 5
Sickle Cell Retinopathy	Ischemia from sickle cells causes neovascularization	Higher in Black populations	2
Macroaneurysm	Retinal artery aneurysm ruptures	Elderly, hypertensive	4 5
Intraocular Tumors	Tumor disrupts blood vessels	Rare	4 5
Others (e.g., vasculitis, wound neovascularization)	Inflammatory/iatrogenic causes	Uncommon	3 5 6

Table 3: Major Causes of Vitreous Hemorrhage

Diabetic Eye Disease

• Proliferative diabetic retinopathy (PDR): The single most common cause in adults, especially those with longstanding or poorly controlled diabetes. Fragile new blood vessels grow on the retina and into the vitreous, where they can rupture easily 2 3 5 7 8.
• Visual impact: Severity can range widely; AMD often results in the poorest vision outcomes 3.

Trauma

• Children & young adults: Trauma remains the leading cause, including obvious injuries and shaken baby syndrome 1 2.
• Mechanisms: Both blunt and penetrating trauma can rupture retinal vessels or tear the retina itself, leading to bleeding 1.

Vascular Disorders

• Retinal vein occlusion: Blocked veins cause retinal ischemia and subsequent abnormal vessel growth that bleeds 2 3 4 5.
• Sickle cell retinopathy: Particularly observed in Black populations, sickle cell disease can cause neovascularization and hemorrhage 2.

Degenerative & Other Causes

• Posterior vitreous detachment (PVD): A common cause in the elderly, PVD can induce retinal tears and hemorrhage as the vitreous pulls away from the retina 4 5.
• Macroaneurysm: Often overlooked, rupture of a retinal artery macroaneurysm can result in a dense hemorrhage 4 5.
• Tumors & others: Rarely, intraocular tumors or wound neovascularization (e.g., after cataract surgery) can be responsible 4 5 6.

Age and Systemic Factors

• Older adults: More likely to have vascular causes (PDR, vein occlusion, AMD) 2 3 4.
• Children: Trauma and regressed retinopathy of prematurity are key causes 1.

Treatment of Vitreous Hemorrhage

Management of vitreous hemorrhage depends on its cause, severity, and the patient’s overall health and vision needs. Modern treatments aim not only to clear the hemorrhage but also to prevent recurrence and preserve vision.

Treatment Approach	Description	Indication/Notes	Source(s)
Observation/Conservative	Monitoring for spontaneous resolution	Small, non-severe bleeds	1 5 8
Laser Photocoagulation (PRP)	Seals leaking vessels, treats neovascularization	PDR, retinal tears	5 7 8
Intravitreal Anti-VEGF Injection	Blocks growth of abnormal vessels	PDR, some AMD cases	7 8 10
Vitrectomy Surgery	Removal of vitreous gel and blood	Non-clearing or severe hemorrhage	1 5 7 8 9
Treatment of Underlying Disease	Systemic or local therapy for root cause	Sickle cell, hypertension, etc.	2 3 5
Future/Experimental Therapies	Pharmacologic vitreous liquefaction	Research phase	5

Table 4: Treatment Options for Vitreous Hemorrhage

Conservative Management

• Observation: Many mild hemorrhages, especially those not caused by ongoing disease, resolve spontaneously. Rest, elevation of the head, and close monitoring are standard 1 5 8.
• When to escalate: Persistent, dense, or recurrent hemorrhage, or evidence of traction on the retina, usually requires intervention 1 5.

Laser Photocoagulation

• Panretinal photocoagulation (PRP): Essential for proliferative diabetic retinopathy and retinal tears, laser therapy shrinks abnormal blood vessels and prevents further bleeding 5 7 8.
• Timing: Usually performed after the hemorrhage clears enough to visualize the retina.

Anti-VEGF Therapy

• Intravitreal injections: Drugs like aflibercept and bevacizumab inhibit the growth of new, leaky blood vessels. These are widely used in diabetic retinopathy and sometimes AMD 7 8 10.
• Efficacy: Some cases resolve with just one or two injections; others require additional interventions 8.

Vitrectomy Surgery

• Procedure: Surgical removal of the vitreous gel and blood, often combined with laser therapy for the underlying cause 1 5 7 8 9.
• Indications: Persistent, dense hemorrhage not clearing on its own, or when there’s a retinal detachment or extensive neovascularization 7 8 9.
• Outcomes: Vision often improves rapidly after surgery. In clinical trials, vitrectomy led to faster clearance of blood and quicker vision recovery, especially in severe cases 7 9.

Treating the Underlying Cause

• Systemic disease control: Managing diabetes, hypertension, or sickle cell disease is essential to prevent recurrence 2 3 5.
• Rare causes: Tumors, wound neovascularization, and inflammation require tailored therapies—including laser, surgery, or systemic medication 6.

Emerging & Future Therapies

• Pharmacologic vitreous liquefaction: Under investigation, these agents may help clear hemorrhage non-surgically in the future 5.

Conclusion

Vitreous hemorrhage is a complex condition that can threaten vision, but early recognition and appropriate management can significantly improve outcomes. Here’s a summary of the main points covered:

• Symptoms include floaters, blurred vision, visual obscuration, and, in children, strabismus or nystagmus.
• Types are primarily classified as traumatic or spontaneous, with trauma leading in children and retinal vascular disease in adults.
• Causes range from proliferative diabetic retinopathy (the most common), trauma, and retinal vein occlusion to less common sources such as macroaneurysm and intraocular tumors.
• Treatment is guided by the underlying cause and may involve observation, laser therapy, anti-VEGF injections, vitrectomy, and systemic disease management.
• Rapid assessment and targeted therapy are crucial for preserving vision and preventing recurrence.

If you or someone you know experiences a sudden change in vision, especially with risk factors such as diabetes or recent trauma, seek prompt ophthalmologic evaluation. Early intervention can make all the difference in protecting sight.