Br J Ophthalmol: first published as 10.1136/bjo.64.7.469 on 1 July 1980. Downloaded from

British Journal of , 1980, 64, 469-471

The acute vitreous haemorrhage

JOHN S. LEAN AND ZDENEK GREGOR From Moorfields Eye Hospital, City Road, London EC] V 2PD

SUMMARY One hundred cases of acute vitreous haemorrhage have been analysed prospectively. It was possible to identify the cause of the haemorrhage at presentation in 79 % of the cases. 40 % were due to retinal tears and only 6% were associated with .

An acute vitreous haemorrhage presents as a Table 1 Causes of vitreous haemorrhage shower of with or without blurring of vision. On examination blood is found in the Cause Percentage vitreous cavity, either within the vitreous gel in the Retinal tears 40 retrohyaloid space or both. A wide variety of Trauma 12 conditions may lead to bleeding of this kind. In 2 Retinal vein occlusion 10 recent series diabetic retinopathy was found to be 6 the commonest cause of nontraumatic vitreous 4 haemorrhage.' 2 4 This paper presents an analysis of causes of 4 vitreous haemorrhage in a prospective series of 100 Posterior vitreous detachment 3 consecutive cases as seen in a busy ophthalmic Malignant melanoma 3 casualty department. We emphasise the possibility 'Vasculitis' 3 of definitive diagnosis at initial presentation in a Sickle cell disease 1 high proportion of cases, the relatively low number Coats's disease 1 of patients with diabetic retinopathy, and conversely Disciform degeneration 1 http://bjo.bmj.com/ the high proportion of cases with retinal tears. Hypertension with macroaneurysm 1 Undiagnosed 4 Materials and methods Lost to follow-up 3 Total 100 One hundred consecutive patients presenting with acute vitreous haemorrhage were entered prospec- HISTORY tively into the study. The patients' medical and 66% of patients complained of floaters only. on September 24, 2021 by guest. Protected copyright. ophthalmic history, presenting symptoms, and Photopsia was a relatively uncommon symptom clinical findings were recorded on a standard form. and was seen combined with floaters in a further Each patient had a full ophthalmic examination 15% of cases. 19% presented only with blurring of including slit-lamp biomicroscopy using the Gold- vision. 11% of patients had had a previous episode mann 3 mirror lens and indirect of vitreous haemorrhage. 12% gave a history of with scleral depression. After the initial assessment ocular trauma immediately preceeding the onset of in the casualty department the patients were gener- their symptoms. 5% were on treatment for hyper- ally admitted for further investigation and manage- tension and 6% were diabetic. ment. The case notes of all the patients were re- viewed after 1 year. AETIOLOGY The cause of the vitreous haemorrhage was diag- Results nosed on presentation in 79% of patients. Of the remainder 14% were diagnosed on follow-up, 4% There were 55 male and 45 female patients. Ninety remained undiagnosed after 1 year and 3% were were Caucasian and there were 10 Negro. lost to follow-up (Table 1). Rhegmatogenous causes. 40% of patients had a Correspondence to Mr J. S. Lean, FRCS. retinal tear. The majority of these (38%) were 469 Br J Ophthalmol: first published as 10.1136/bjo.64.7.469 on 1 July 1980. Downloaded from

470 John S. Lean and Zdenek Gregor

diagnosed on presentation; the remaining 2 cases tion be identified. In 3 patients a vitreous haemorr- were diagnosed on follow-up and did not progress hage was the initial symptom of a choroidal malig- to a retinal detachment. Three patients had flat nant melanoma. Two of these were diagnosed on retinal tears which had been previously treated presentation and 1 was diagnosed on follow-up. with cryotherapy. In all these cases a retinal tear There was one case of Coats's disease, and there was bridged by a patent retinal vessel and showed was one case which appeared to have bled from signs of vitreous traction on the operculum. In the disciform degeneration of the macula. absence of any other pathology this combination of Undiagnosed. Four cases have remained undiag- signs was taken as evidence of the source of bleeding. nosed. In 1 case a large vitreous haemorrhage has Four patients presented with acute vitreous failed to clear, the eye has now no perception of haemorrhage as the first symptom of retinal detach- light, and it is assumed that the patient has a total ment. All these patients were diagnosed at presen- retinal detachment. In the other 3 cases a diffuse tation. vitreous haemorrhage was found at the time of Trauma. In 12 cases the vitreous haemorrhage presentation, but this has cleared spontaneously was related to blunt trauma. Five patients had with a good visual result. No pathology has been posterior vitreous detachment at the time of presen- found except that in all 3 cases a posterior vitreous tation. In these cases the cause of bleeding was detachment is now present. attributed to an acute posterior vitreous detachment Three patients have been lost to follow-up. in association with the trauma. However, in 2 cases no posterior vitreous detachment was identi- Discussion fied, and haemorrhage was present entirely in the vitreous gel. In the remaining 5 cases extensive In this series the commonest single diagnosis (40%) haemorrhage made the assessment of the vitreous was that of a retinal tear. Only 5% of these could and the impossible. not be diagnosed at the time of initial presentation. New vessel formation. Nine patients presented The majority were fresh tears associated with the with bleeding from neovascular complexes asso- recent onset of symptoms. However, 3 patients ciated with a retinal vein occlusion. Six of these with treated horseshoe tears bled from a patent patients were diagnosed on presentation; 3 patients retinal vessel crossing the tear. An earlier report3 had extensive bleeding and diagnosis was only suggested that anterior extension of the retinal tear possible on follow-up. A further 6 patients had was responsible for recurrent bleeding. In our cases diabetes. In 3 of these there was evidence of neo- the retinal vessel seemed a more likely source of vascularisation, but in 1 new vessels could not be haemorrhage. Such crossing vessels are prone to http://bjo.bmj.com/ identified. In the remaining 2 patients assessment cause recurrent haemorrhages until they either was impossible due to extensive bleeding. One become occluded or their course interrupted.4 patient had . Acute posterior vitreous detachment in the absence Retinoschisis. This was observed in 4 patients of a frank retinal tear was identified in a further 3 with vitreous haemorrhage. The amount of hae- patients. morrhage was minimal and tended to be in the In contrast to the studies of Lincoff et al.2 and retrohyaloid space. Abnormal paravascular vitreo- Morse et al.1 we found diabetic retinopathy to be on September 24, 2021 by guest. Protected copyright. retinal adhesions with punctate retinal haemorrhage an uncommon cause of an acute vitreous haemorr- were also observed in the area of retinoschisis. hage. We feel this partly reflects a difference in the Acute posterior vitreous detachment. Three patients selection of our patients. In this hospital diabetics presented with an acute posterior vitreous detach- are managed in a specific diabetic clinic and there- ment which was recognised as the combination of fore tend not to present with recurrent bleeding to posterior vitreous detachment, punctate retinal the casualty department. In support of this, of our haemorrhages, and the presence of blood in the 6 patients with diabetic retinopathy 5 were experien- retrohyaloid space. No other ocular pathology was cing their first vitreous haemorrhage at the time of found in any of these 3 patients. presentation. Hypertension. In 5 patients the vitreous haemorr- Acute vitreous haemorrhage in association with hage was associated with systemic hypertension. In retinoschisis is well recognised,5 although the 1 of these patients a macroaneurysm had ruptured relatively high number of cases in this series is and in the remainder there was no apparent source unusual. In these patients we were able to identify of bleeding. abnormal paravascular vitreoretinal adhesions Miscellaneous. 'Retinal vasculitis' was associated which appeared to be the cause of bleeding. In all with vitreous haemorrhage in 3 patients, though cases the haemorrhage was slight and cleared in none of these cases could definite neovascularisa- rapidly. Br J Ophthalmol: first published as 10.1136/bjo.64.7.469 on 1 July 1980. Downloaded from

The acute vitreous haemorrhage 471

Choroidal malignant melanomas infrequently Retinal tears form the largest single group and can give rise to vitreous haemorrhage. Such bleeding be almost always identified (95%). probably implies necrosis of the tumour mass.6 In 1 patient the vitreous haemorrhage was sufficiently We thank Mr R. K. Blach for his advice and encouragement dense that the correct diagnosis was not initially and Miss Heather Lucas for secretarial assistance. suspected. It is interesting that systemic hypertension, References although frequently thought to be associated with 'Morse PH, Aminlari A, Scheie GH. Spontaneous vitreous vitreous haemorrhage, was relatively unusual as haemorrhage. Arch Ophthalmol 1974; 92: 297-8. an our aetiological factor. Ten of patients had 2Lincoff H, Kreisig I, Wolkstein M. Acute vitreous haemorr- systemic hypertension, but 5 of these were asso- hage: a clinical report. Br J Ophthalmol 1976; 60: 454-8. ciated with a branch vein occlusion and consequent 3Delaney WV Jr. Retinal tear extension through the cryo- surgical scar. Br J 55: 205-9. neovascularisation, 1 with a macroaneurysm Ophthalmol which 4Robertson DM, Norton EWD. Retinal breaks. Am J had ruptured, and in only 4 cases did the hyper- Ophthalmol 1973; 75: 395-404. tension itself appear to be directly related to the 5Tolentino Fl, Schepens LC, Freeman MH. Vitreoretinal vitreous haemorrhage. Disorders, Diagnosis and Management. Philadelphia, This study demonstrates that the cause of an London, Toronto: Saunders, 1976; 254-5. 6Gass DJ. Haemorrhage into the vitreous; presenting acute vitreous haemorrhage can be accurately manifestation of malignant melanoma of the choroid. established at presentation in almost 80% of cases. Arch Ophthalmol 1963; 69: 778-9. http://bjo.bmj.com/ on September 24, 2021 by guest. Protected copyright.