Vitreous haemorrhage
Bleeding into the vitreous (proliferative diabetic retinopathy, PVD/tear, trauma)
Overview
Bleeding into the vitreous cavity, causing sudden painless floaters, haze or visual loss with loss of the red reflex. The commonest cause is proliferative diabetic retinopathy (bleeding from new vessels); also retinal tear/PVD, retinal vein occlusion and trauma. Needs referral to find and treat the source.
Recognise
- Sudden painless floaters, 'red haze', cobwebs, or visual loss depending on density
- Reduced/absent red reflex; the retina may be obscured from view
- Causes: proliferative diabetic retinopathy (most common), retinal tear/PVD, RVO, trauma, sickle/retinal neovascularisation
Red flags
- Dense haemorrhage obscuring the fundus → B-scan to exclude an underlying retinal detachment/tear
- Diabetic with new vitreous haemorrhage → proliferative disease needing panretinal photocoagulation
Differentials & how to tell them apart
Investigations
Fundoscopy (often obscured); B-scan ultrasound to exclude retinal detachment/tear; identify the source (diabetic neovascularisation, tear).
Management
Refer; B-scan to exclude detachment + treat the source
- 1Refer to ophthalmology. B-scan ultrasound if the fundus is obscured to exclude a retinal detachment. Posture upright to let blood settle.Gate: Always exclude an underlying retinal tear/detachment behind a dense vitreous haemorrhage with B-scan — it changes the urgency and management
- 2Treat the source: panretinal photocoagulation ± anti-VEGF for proliferative diabetic retinopathy; retinopexy for a tear; vitrectomy if non-clearing or detachment present.
Key points
Sudden floaters/haze + loss of the red reflex = vitreous haemorrhage; in a diabetic it means proliferative retinopathy. Ultrasound to exclude a hidden detachment.
Monitor & prognosis
Clearance over weeks; treat underlying disease.
Often clears; depends on the cause.
Source: RCOphth; cross-ref diabetic retinopathy