Vitreous HemorrhageMANAGEMENT

OPHTHALMOLOGIC PRESENTATIONS · 12 SECTIONS

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475 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Acute angle-closure glaucoma Central retinal artery occlusion Central Retinal Vein Occlusion Chemical eye injury Corneal abrasion Corneal ulcer Endophthalmitis Globe rupture Herpes zoster ophthalmicus Hyphema Iritis-Uveitis Ocular foreign body Optic Neuritis Orbital cellulitis Orbital Floor Fracture (Blowout)Posterior vitreous detachment Retinal detachment Retrobulbar hematoma and orbital compartment syndrome Vitreous Hemorrhage

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp36

Immediate Red Flags

›Critical presentations requiring immediate action

›Concurrent retinal detachment with vision loss to light perception only

›Emergent ophthalmology consultation within minutes

›Bed rest, head elevated 30-45 degrees, bilateral patching

›Open globe injury with vitreous prolapse

›Rigid eye shield (do NOT patch), NPO, IV antiemetics

›Emergent ophthalmology surgical consultation

›Terson syndrome (VH + severe headache/altered mental status)

›CT head non-contrast immediately to rule out subarachnoid hemorrhage

›Neurosurgery and ophthalmology dual consultation

Stabilization Priorities

›Airway, breathing, circulation assessment for concurrent systemic emergency

›SAH protocol if Terson syndrome suspected

›Establish large-bore IV access and continuous cardiac monitoring

›Nimodipine 60 mg PO/NG q4h if SAH confirmed

›Acute secondary glaucoma from VH

›IOP target reduction to less than 21 mmHg

›Timolol 0.5% ophthalmic drops 1 drop to affected eye

›Acetazolamide 500 mg IV if IOP severely elevated and no sulfa allergy

Consult Triggers

›Ophthalmology consultation indications

›Retinal detachment identified or strongly suspected on POCUS or exam

›Same-day emergent consultation

›Dense VH obscuring fundus without identifiable etiology

›Same-day urgent consultation

›New VH with vitreous pigment (Shafer sign)

›Same-day consultation; probability of retinal tear rises from 14% to 62%

02History/hx46

Presenting Symptoms

›Visual symptom character

›Sudden shower of floaters

›Red or dark haze across vision

›Cobweb or smoke-like visual disturbance

›Complete visual loss (light perception only in dense VH)

›Onset and progression

›Sudden versus gradual onset

›Onset during sleep, exertion, or Valsalva maneuver

›Progression over hours to days

Alarm Symptom Screening

›Curtain or shadow in visual field

›Suggests retinal detachment until proven otherwise

›Vertical or horizontal distribution, fixed versus moving

›Photopsias (flashing lights)

›Indicates vitreoretinal traction and possible retinal tear

›Temporal versus central location

›Eye pain

›Absence of pain typical of VH

›Pain suggests hyphema, glaucoma, endophthalmitis, or open globe

›Severe headache or neck stiffness

›Raises concern for Terson syndrome from SAH

Ocular History

›Laterality: unilateral versus bilateral

›Bilateral VH suggests Terson syndrome, blood dyscrasias, or leukemia

›Prior vitreous hemorrhage episodes

›Recurrent VH suggests proliferative retinopathy

›Prior retinal tears, detachments, or vitreoretinal surgery

03Physical Exam/exam37

Visual Acuity

›Corrected visual acuity in each eye separately

›Range from mildly decreased to light perception only depending on hemorrhage density

›Count fingers, hand motion, light perception documentation if acuity severely reduced

Pupillary Exam

›Pupil size and reactivity bilaterally

›Relative afferent pupillary defect (RAPD)

›Indicates extensive retinal detachment or optic nerve involvement

›Positive RAPD changes management to emergent consultation

Confrontation Visual Fields

›Visual field assessment in all quadrants

›Curtain or shadow field defect

›Highly suspicious for retinal detachment

›Peripheral field loss pattern versus central

›Altitudinal defect versus quadrantanopia

Slit Lamp Biomicroscopy

›Anterior chamber examination

›Hyphema (layered blood in anterior chamber)

›Hypopyon (white layering suggesting endophthalmitis)

›Rubeosis iridis (iris neovascularization before dilation)

›Vitreous examination technique

›Beam focused behind lens while patient looks up, then down, then straight

›Red blood cells suspended in vitreous cavity (confirms VH)

›Shafer sign (tobacco dust — pigmented vitreous cells)

›Strongly associated with retinal tear

›Increases probability of retinal tear from 14% to 62%

Intraocular Pressure

›IOP measurement in both eyes

04Differential Diagnosis/ddx38

Must-Not-Miss Diagnoses

›Retinal detachment (rhegmatogenous)

›Curtain-like field loss, may coexist with VH

›17% of PVD-associated VH develop RRD; risk highest in first 3 weeks

›ICD-10: H33.0

›Open globe injury

›Trauma history, irregular or teardrop pupil, low IOP, uveal prolapse

›ICD-10: S05.6

›Terson syndrome

›Bilateral VH with concurrent SAH; mortality of SAH 40-50%

›ICD-10: H43.1 + I60

Common Causes

›Proliferative diabetic retinopathy

›Most common cause (32-39%); neovascularization on disc or elsewhere bleeds

›ICD-10: E11.351

›Posterior vitreous detachment with retinal tear

›Flashes, shower of floaters, vitreous pigment

›ICD-10: H43.81 + H33.3

›Posterior vitreous detachment without tear

›Benign cause; minimal VH; ICD-10: H43.81

›Retinal vein occlusion (central or branch)

›Painless vision loss, flame hemorrhages, cotton-wool spots

›Accounts for 7-11% of VH; ICD-10: H34.8

Less Common but Important

›Retinal macroaneurysm

›Hypertension-associated; frequently overlooked; diagnosed late

›ICD-10: H35.04

›Sickle cell retinopathy

05Laboratory Tests/lt29

Metabolic Screen

›Blood glucose

›Point-of-care fingerstick in all patients with VH

›Hyperglycemia supports proliferative diabetic retinopathy as etiology

›HbA1c

›Reflects glycemic control over prior 3 months

›Target less than 7% to reduce diabetic retinopathy progression

Complete Blood Count

›CBC with differential

›Thrombocytopenia (platelets less than 50 x10^9/L) contributes to VH

›Leukocytosis or blast cells suggest leukemic infiltration

›Anemia with hemoglobin less than 80 g/L contributes to bleeding risk

Coagulation Studies

›Prothrombin time and INR

›Therapeutic range for VKA 2.0-3.0 (higher range for mechanical valves)

›Supratherapeutic INR greater than 3.0 increases hemorrhage risk significantly

›Activated partial thromboplastin time

›Elevated in hemophilia, direct thrombin inhibitor use, lupus anticoagulant

›Anti-Xa level if on LMWH or direct oral anticoagulants

Sickle Cell Screen

›Hemoglobin electrophoresis

›Indicated in Black patients, Mediterranean descent, or unknown hemoglobin status

›HbSS and HbSC both cause sickle cell retinopathy

›Sea-fan neovascularization in HbSC more than HbSS

Inflammatory Markers

›ESR and CRP

›Indicated if giant cell arteritis or systemic vasculitis suspected

›ESR greater than 50 mm/hr and CRP greater than 2.45 mg/dL support GCA

06Diagnostic Tests/dt41

Scoring Systems

›No validated clinical scoring system exists for VH severity stratification in the ED

›Severity classification by clinical assessment

›Mild: floaters, reduced acuity, fundus partially visible

›Moderate: significant acuity loss, fundus partially obscured, B-scan required

›Dense: no fundus view, light perception only, emergent B-scan and consultation

›RRD risk stratification from evidence

›VH presence increases retinal tear probability from 14% baseline to 62%

›Male sex: HR 2.90 for RRD in PVD-associated VH

›Younger age at time of PVD-associated VH increases RRD risk

MRI

›MRI orbit indications

›Not routine for isolated VH; reserve for specific clinical scenarios

›Suspected intraocular tumor when CT inconclusive

›Orbital cellulitis or mass lesion evaluation

›MRI brain indications

›Terson syndrome workup if CT negative but clinical suspicion high

›MRI FLAIR: more sensitive than CT for subacute SAH

›Contraindications

›Suspected metallic intraocular foreign body (CT orbits first)

›CT orbits indications

›Ocular trauma with suspected fracture or foreign body

›Non-contrast CT orbits with 1-3 mm cuts

›Identifies metallic foreign body, orbital wall fracture, open globe signs

›CT head non-contrast for Terson syndrome workup

›Sensitivity 92-98% for SAH within 12 hours of onset

›Sensitivity decreases to approximately 85% at 24 hours

07Disposition/dispo29

Emergent Consultation and Admission

›Indications for same-day emergent ophthalmology consultation

›Retinal detachment identified or strongly suspected

›Surgical repair generally within 24 hours for macula-off; immediate for macula-on

›Open globe or penetrating ocular trauma

›NPO, eye shield, emergent operative planning

›Acute secondary glaucoma (IOP greater than 30 mmHg with VH or hyphema)

›Medical management then possible surgical drainage

›Terson syndrome with confirmed SAH

›Neurosurgery admission; ophthalmology consulted during admission

›Suspected endophthalmitis

›Intravitreal antibiotics within hours; ophthalmology consultation

Urgent Referral Within 24-48 Hours

›Indications for urgent but non-emergent ophthalmology referral

›Dense VH obscuring fundus with negative or equivocal B-scan

›RRD risk remains elevated; needs serial follow-up

›Vitreous pigment (Shafer sign) identified

›High probability of occult retinal tear; referral within 24 hours

›New VH in known diabetic patient without recent ophthalmology evaluation

›PDR workup and possible laser or anti-VEGF initiation

Discharge Criteria

›Conditions allowing safe ED discharge with close follow-up

›Mild to moderate VH with fundus at least partially visible

›No retinal detachment identified

›No retinal tear or Shafer sign

›Known benign etiology (PVD in elderly, well-controlled vascular risk factors)

›Clear return precautions provided in writing

›Confirmed ophthalmology follow-up arranged within 1-2 weeks

08Treatment/t60

Immediate ED Measures

›Positioning and activity restriction

›Head of bed elevation 30-45 degrees

›Allows blood to settle inferiorly, clearing visual axis

›AAO Preferred Practice Pattern recommendation

›Avoid Valsalva maneuvers, heavy lifting, bending at waist

›Reduces risk of rebleeding or extension

›Bilateral patching may aid settling per AAO guidance

IOP Management

›Elevated IOP treatment (IOP greater than 25 mmHg)

›Topical beta-blocker

›Timolol 0.5% ophthalmic solution 1 drop affected eye twice daily

›Onset 20-30 minutes; maximum effect at 1-2 hours

›Contraindicated in asthma, COPD, bradycardia, heart block

›Topical alpha-2 agonist

›Brimonidine 0.1-0.2% ophthalmic solution 1 drop affected eye three times daily

›Avoid in patients on MAOIs

›Carbonic anhydrase inhibitor if topical agents insufficient

›Acetazolamide 500 mg IV or 250 mg PO for acute IOP crisis

›Contraindicated in sulfa allergy and renal failure

›Monitor for hypokalemia

›Methazolamide 50-100 mg PO twice daily as alternative

›Topical cycloplegic for comfort and to stabilize iris movement

›Atropine 1% ophthalmic solution 1 drop to affected eye once to twice daily

Anti-VEGF Therapy for PDR-Related VH

›Intravitreal anti-VEGF for proliferative diabetic retinopathy

›Aflibercept 2 mg intravitreal injection

›DRCR Protocol AB: similar 2-year visual outcomes to vitrectomy with PRP

09Special Populations/sp47

Pregnancy

›VH in pregnancy considerations

›Proliferative diabetic retinopathy may accelerate during pregnancy

›Hormonal changes, increased blood volume, and vascular changes drive progression

›Ophthalmology referral in first trimester for baseline dilated exam

›Anti-VEGF therapy in pregnancy

›Systemic absorption with intravitreal anti-VEGF agents crosses placenta

›Avoid bevacizumab, ranibizumab, and aflibercept in pregnancy when possible

›Laser photocoagulation preferred when feasible as safer alternative

›IOP-lowering medications

›Timolol: Category C; associated with fetal bradycardia and respiratory depression

›Acetazolamide: avoid in first trimester; teratogenic in animal models

›Brimonidine: avoid near term; neonatal central nervous system depression reported

›Preeclampsia-associated VH

›Rare; associated with severe hypertension and retinal detachment

›Deliver if severe features; ophthalmology consultation

Geriatric

›VH in elderly patients

›Posterior vitreous detachment is most common cause in patients over 65

›PVD incidence increases sharply after age 50; near-universal by age 80

›Spontaneous clearance of PVD-associated VH in 62% within weeks to months

›Medication considerations

›Multiple anticoagulant and antiplatelet use common; careful medication review

›Rivaroxaban ROR 11.14, dabigatran ROR 5.83 for intraocular hemorrhage

›Avoid anticholinergics (atropine drops may exacerbate prostatic symptoms or confusion)

›Wet AMD with subretinal hemorrhage extending into vitreous

›Distinct from classic VH; may have submacular blood threatening central vision

›Emergent anti-VEGF consideration; refer to retina specialist urgently

10Background/b48

Epidemiology

›Incidence and prevalence

›Incidence approximately 7 per 100,000 population annually

›Bilateral VH is rare; suggests systemic etiology

›Etiology distribution

›Proliferative diabetic retinopathy: 32-39% of all VH cases

›Retinal tears with or without detachment: 12-30%

›Retinal vein occlusion: 7-11%

›Posterior vitreous detachment without retinal tear: 6-8%

›Sickle cell retinopathy: greater than 15% of spontaneous VH in Black patients

›Age and sex distribution

›Peak incidence age 45-65 (PVD-driven); PDR-related VH in younger diabetics

›Male sex: HR 2.90 for RRD in PVD-associated VH

›Outcomes data

›Spontaneous clearance of PVD-associated VH: 62% eventually clear

›After 60 days, only 48% of dense VH have cleared spontaneously

›VH develops in 46-48% of PDR eyes over 5 years even with treatment

Pathophysiology

›Mechanisms of bleeding into vitreous cavity

›Neovascularization rupture (PDR, sickle cell, vein occlusion)

›New vessels lack pericyte support and rupture spontaneously

›PDR neovascularization responds to VEGF blockade

›Posterior vitreous detachment with retinal vessel traction

›Vitreous collagen fibers contract and pull on retinal vessels

›Bridging vessels to vitreous tear and bleed before or during PVD

›Retinal tear with adjacent vessel injury

›Retinal vascular disruption produces hemorrhage tracking into vitreous

›Direct trauma to ocular vasculature

11Patient Discharge Instructions/pdi28

copy discharge instructions

›Vitreous hemorrhage discharge instructions

›What happened to your eye

›Bleeding occurred inside your eye into the gel-like vitreous

›This can cause floaters, haze, or vision loss

›The cause must be determined by an eye specialist

›Activity restrictions

›Sleep with your head elevated on 2-3 pillows for the next 1-2 weeks

›Avoid heavy lifting, straining, or bending below your waist

›Avoid contact sports and strenuous exercise until seen by eye doctor

›Avoid straining during bowel movements; use stool softener if needed

›Medications

›Take all prescribed eye drops as directed

›Do not stop blood thinners without first calling your prescribing doctor

›Avoid aspirin and ibuprofen unless medically necessary

›What to expect

›Vision may remain blurry or hazy for days to weeks or longer

›The blood may take weeks to months to clear

›You may see more floaters or dark spots as the blood settles

›Follow-up

›Eye specialist appointment arranged for you; attend this appointment

›If your appointment is more than 48 hours away and symptoms change, return to emergency

›Return to the emergency department immediately if

›A curtain, shadow, or dark veil appears in your vision (may indicate retinal detachment)

›Sudden complete or severe worsening of vision

›New eye pain or your eye becomes red

›New flashing lights in your vision

›Severe headache, neck stiffness, or confusion (may indicate brain bleeding)

12References/r36

Guidelines and Key Sources

›American Academy of Ophthalmology Preferred Practice Patterns 2025

›Kim SJ, Bailey ST, Kovach JL, et al. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration PPP. Ophthalmology. 2025

›Serial B-scan and close follow-up for VH with PVD; weekly visits recommended

›Lim JI, Kim SJ, Bailey ST, et al. Diabetic Retinopathy PPP. Ophthalmology. 2025

›Anti-VEGF and PPV indications for PDR-related VH; IOP management guidelines

Landmark Trials

›DRCR Network Protocol AB (JAMA 2020)

›Antoszyk AN, Glassman AR, Beaulieu WT, et al. JAMA. 2020

›RCT comparing aflibercept versus vitrectomy with PRP for VH from PDR

›Similar 2-year visual acuity outcomes; vitrectomy provides faster early recovery

›Glassman AR, Beaulieu WT, Maguire MG, et al. JAMA Ophthalmology. 2021

›Secondary analysis of DRCR Protocol AB; confirmed equivalent outcomes at 12 weeks

Diagnostic Evidence

›Hollands H, Johnson D, Brox AC, et al. JAMA. 2009

›Acute-Onset Floaters and Flashes: Is This Patient at Risk for Retinal Detachment?

›Shafer sign increases retinal tear probability from 14% to 62%

›Foundational evidence for risk stratification in VH with floaters

›Lahham S, Shniter I, Thompson M, et al. JAMA Network Open. 2019

›POCUS in Diagnosis of Retinal Detachment, VH, and Vitreous Detachment in ED

›POCUS sensitivity 97%, specificity 92% for retinal detachment in ED setting

›Supports routine POCUS use by emergency physicians in VH evaluation

›Hasbolat H, Christensen UC, Lund-Andersen C. Ophthalmology. 2026

›VH Due to PVD: Incidence of RRD and Spontaneous Clearance During Observation

›17% of PVD-associated VH develop RRD; risk highest in first 3 weeks

›Male sex HR 2.90 for RRD; 62% spontaneous clearance rate

Pharmacology and Safety

›Talany G, Guo M, Etminan M. Eye. 2017

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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