Kamilė Grigaitė1, Martynas Špečkauskas2
1Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania
2Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Background: Vitreous hemorrhage (VH) is the presence of extravasated blood within the space defined by the internal limiting membrane of the retina posteriorly and laterally, the nonpigmented epithelium of the ciliary body laterally, and the lens zonular fibers and posterior lens capsule anteriorly. The treatment of unknown-cause VH can be conservative, but in some cases, such as retinal tear or detachment, it is suggested to perform pars plana vitrectomy (PPV) early to avoid irreversible vision impairment. However, it is important to evaluate the possible risks of surgical intervention and prognosis of vision acuity associated with the leading cause of VH.
The aim: to present a clinical case of vitreous hemorrhage with retinal tears diagnosed in the Hospital of Lithuanian University of Health Sciences Kauno Klinikos and review the latest scientific literature of vitreous hemorrhage causes, findings in ultrasonography and treatment.
Material and methods: recently published studies were reviewed to evaluate the latest findings in vitreous hemorrhage causes, findings in ultrasonography and treatment. Clinical case of vitreous hemorrhage was presented. Databases from the subscription list of Lithuanian University of Health Sciences were selected: PubMed, SpringerLink, ScienceDirect.
Results: A 61-year-old male patient complaining of a sudden vision worsening and cobwebs in the vision field of the left eye underwent ophthalmic examination. Ultrasonography (US) of the left eye (LE) has been done because of the lack of information during the fundoscopic examination. It showed acoustic hyperdensity in the vitreous, corresponding to vitreous hemorrhage. Urgent PPV was performed to avoid retinal detachment.
Conclusion: VH is a common reason of painless unilateral visual worsening which can be irreversible. US has proven to be an effective diagnostic tool, which helped to identify VH caused by retinal tears and determine the urgency of surgical intervention. PPV has shown to be the main treatment method for dense VH caused by retinal tears with minimal complications risk and promising outcomes.
Keywords: vitreous hemorrhage, B-scan, ultrasonography, vitrectomy.
https://doi.org/10.53453/ms.2021.06.23
Journal of Medical Sciences. Jun 30, 2021 - Volume 9 | Issue 5. Electronic - ISSN: 2345-0592
249
Medical Sciences 2021 Vol. 9 (5), p. 249-255, https://doi.org/10.53453/ms.2021.06.23
The role of ultrasonography in management of vitreous
hemorrhage: case report and literature review
Kamilė Grigaitė
1
, Martynas Špečkauskas
2
1
Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania
2
Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Background: Vitreous hemorrhage (VH) is the presence of extravasated blood within the space defined by
the internal limiting membrane of the retina posteriorly and laterally, the nonpigmented epithelium of the
ciliary body laterally, and the lens zonular fibers and posterior lens capsule anteriorly. The treatment of
unknown-cause VH can be conservative, but in some cases, such as retinal tear or detachment, it is
suggested to perform pars plana vitrectomy (PPV) early to avoid irreversible vision impairment. However,
it is important to evaluate the possible risks of surgical intervention and prognosis of vision acuity
associated with the leading cause of VH.
The aim: to present a clinical case of vitreous hemorrhage with retinal tears diagnosed in the Hospital of
Lithuanian University of Health Sciences Kauno Klinikos and review the latest scientific literature of
vitreous hemorrhage causes, findings in ultrasonography and treatment.
Material and methods: recently published studies were reviewed to evaluate the latest findings in vitreous
hemorrhage causes, findings in ultrasonography and treatment. Clinical case of vitreous hemorrhage was
presented. Databases from the subscription list of Lithuanian University of Health Sciences were selected:
PubMed, SpringerLink, ScienceDirect.
Results: A 61-year-old male patient complaining of a sudden vision worsening and cobwebs in the vision
field of the left eye underwent ophthalmic examination. Ultrasonography (US) of the left eye (LE) has been
done because of the lack of information during the fundoscopic examination. It showed acoustic
hyperdensity in the vitreous, corresponding to vitreous hemorrhage. Urgent PPV was performed to avoid
retinal detachment.
Conclusion: VH is a common reason of painless unilateral visual worsening which can be irreversible. US
has proven to be an effective diagnostic tool, which helped to identify VH caused by retinal tears and
determine the urgency of surgical intervention. PPV has shown to be the main treatment method for dense
VH caused by retinal tears with minimal complications risk and promising outcomes.
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250
Keywords: vitreous hemorrhage, B-scan, ultrasonography, vitrectomy.
Introduction
Vitreous hemorrhage (VH) is the presence of
extravasated blood within the space defined
by the internal limiting membrane of the
retina posteriorly and laterally, the
nonpigmented epithelium of the ciliary body
laterally, and the lens zonular fibers and
posterior lens capsule anteriorly [1]. VH was
reported to have an incidence of 7 cases per
100 000 persons each year in Europe,
however, more recent analysis suggests VH
to have an incidence of 4.8 cases per 10,000
persons yearly [2,3]. Identified etiologies of
nontraumatic VH are proliferative diabetic
retinopathy (PDR), retinal tear, retinal vein
occlusion (RVO), retinal vasculitis,
neovascular age-related macular
degeneration (AMD), retinal arterial
macroaneurysm (RAM), posterior vitreous
detachment (PVD), polypoidal choroidal
vasculopathy (PCV), tumors and blood
dyscrasias [4,5]. The most common symptom
of VH is a monocular painless sudden or
gradual progressive vision loss. Symptoms,
such as multiple visualized floaters, flashes,
cobwebs, dark streaks or lines in vision,
cloudy vision or visual haze, may be involved
[6].
The treatment of unknown origin VH can be
conservative. If the blood in the vitreous has
not been absorbed after 2 to 3 months, pars
plana vitrectomy (PPV) is advised [2,7].
However, in some cases, such as retinal tear
or detachment, which can progress quickly
during this period, it is suggested to perform
early PPV to avoid possible irreversible
vision impairment. The primary cause of VH
should be detected since the visual prognosis
is dependent on it [8]. In cases where fundus
is invisible during an ophthalmological
examination, it is recommended to use an
ultrasonography (US) to determine the
urgency of the surgical intervention. B scan
US is considered to be a helpful tool in
finding out some causes of VH, especially of
retinal tears and detachments, when the
hemorrhage is too dense to enable
funduscopic evaluation [7]. Although early
PPV might lower the overall rate of retinal
detachment, it is important to evaluate the
possible risks of the surgical intervention and
prognosis of vision acuity associated with the
leading cause of VH [2,9].
Case presentation
A 61-year-old male presented for
ophthalmological examination in the
Hospital of Lithuanian University of Health
Sciences Kaunas Klinikos complaining of a
sudden vision worsening and cobwebs in the
vision field of the left eye (LE). Symptoms
progressed rapidly and the patient's vision
became hazy. Patient has a vision impairment
of the right eye (RE), which occurred during
his childhood due to chorioretinitis. RE and
LE had gone through surgical treatment of
phacoemulsification with intraocular lens
(IOL) implantation one and two years ago,
respectively.
Ophthalmological examination was carried
out and the best corrected visual acuity was
0.1 in the RE and only hand movement could
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251
be recognised from a 30 cm distance in the
LE. The intraocular pressure (IOP) of his
both eyes was 17.3 mmHg. There were no
clinically important alterations in the anterior
segment during slit-lamp biomicroscopy,
besides endocapsular IOL in LE and RE.
Fundoscopic examination of RE revealed
chronic oedema of the optic nerve disc
(OND), old pigmented chorioretinal scar in
the macula area, surrounded by atrophic
retina, narrow, empty vessels in the temporal
quadrants [Figure 1]. However, no fundus
details could be seen in the LE because of the
dense vitreous hemorrhage [Figure 2].
Figure 1. Fundus image of the right eye: chronic oedema of the optic nerve disc with old pigmented
chorioretinal scar in the macula area and narrow, empty vessels in the temporal quadrants.
Figure 2. Fundus image of the left eye: dense vitreous hemorrhage.
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In addition, US of the RE has been completed because of lack of information during the fundoscopic
examination. It showed acoustic hyperdensity in the vitreous, corresponding to vitreous hemorrhage.
Possible retinal tears in the superior quadrants were observed also [Figure 3].
Figure 3. B-scan ultrasonography: acoustic hyperdensity in the vitreous with possible retinal tears in the
superior medial quadrants (white arrow).
Urgent PPV was performed in which vitreous body with blood were removed. Retinal tears were confirmed
at 11 and 1 o’clock and endolaser photocoagulation was applied. [Figure 4]. Tamponade agent
perfluoropropane (C
3
F
8
) gas was used to provide surface tension across retinal tears, which prevented
further fluid flow into the subretinal space until the chorioretinal adhesion provides a permanent seal.
Figure 4. Retinal tear observed during pars plana vitrectomy at 11 o’clock.
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Next day after the surgery patient could
recognise only hand movements and distorted
light in LE because of the gas in the vitreous
chamber. Postoperative examination showed
mild postoperative irritations, gas in vitreous
cavity, normal OND and attached retina. After
a short recovery patient was discharged from
the hospital.
One week later control ophthalmic evaluation
was performed, and the best corrected visual
acuity was 0.06 in the RE and 0.9 in the LE.
IOP of the patient’s RE was 14,0 mmHg and
35,4 mmHg of the LE. High IOP in the LE was
likely caused by topical glucocorticosteroids
treatment by which was discontinued.
Fundoscopy showed small amounts of
remaining C
3
F
8
gas in the LE and attached
retina. After 3 weeks, visual acuity increased to
1,0 in the LE eye, IOP was normal in both eyes
and C
3
F
8
gas almost entirely resolved.
Discussion
VH is a severe and potentially blinding
complication caused by retinal vascular
disorders with or without associated ischemia,
break-through bleeding, or rupture of blood
vessels [4,10]. Since vitrectomy is an invasive
surgery with well-known complications, such
as, endophthalmitis, postoperative hypotony,
iatrogenic retinal tears or detachment, cataract,
secondary glaucoma, macular oedema,
choroidal hemorrhage or ocular venous air
embolism, some physicians choose a
conservative approach to manage VH [5,11].
Old age, poor preoperative visual acuity in the
affected eye, poor preoperative visual acuity
and drusen in the fellow eye are considered to
be risk factors to perform PPV for possible
insufficient visual results after the surgery in
patients with unknown origin VH [8]. US has
proven to be a useful tool in determining the
urgency of an operation by allowing to
diagnose certain causes of VH and select
patients who demand early PPV [12]. Studies
show high sensitivity and specificity in
detecting retinal tears in PVD patients,
described as a short, discontinued, highly
reflective membranous reflection, adhering to
the peripheral posterior wall [13]. A sharply
defined, reflective linear membrane anchored
to the optic disc is a sign of retinal detachment,
while vitreous detachment in US is defined as
hyperechoic membrane, separated from the
retina [14].
In this case we presented VH caused by several
retinal tears that required early PPV. Retinal
tears were detected by an US B-scan, which
helped to determine the need of early surgical
intervention and avoid possible irreversible
vision impairment. However, sensitivity of tear
detection by US was assessed in some other
studies and ranged between 44% and 92% [15].
The size of retinal tears and the expertise of the
US operator might be the main causes of this
wide range of sensitivity [7]. Analysis suggests
that early treatment is advised for dense
vitreous hemorrhage associated with retinal
tears since there is a greater risk of
vitreoretinopathy [5]. Compared with other
studies, early PPV should be considered more
carefully in cases where VH is caused by PDR.
Even if PPV is regarded to be an effective
treatment, the visual results after the surgery
may be lower than expected because of the high
risk of postoperative recurrent VH and
neovascular glaucoma associated with PDR
[16,17]. Recent studies also revealed that the
outcome of vitrectomy among patients with
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AMD and PCV strongly differ, demonstrating
significantly better long-term visual results in
PCV [18–21]. In patients with PVD, delayed
clearance of VH is a major risk factor for the
occurrence of retinal tears or retinal
detachment, which can also induce proliferative
vitreoretinopathy [22,23]. Therefore in PVD
patients PPV is recommended instead of a more
conservative approach [24]. Owing to the high
incidence of spontaneous resolution and
minimal consequences, patients with RAM and
reduced vision due to intraretinal, preretinal, or
vitreous hemorrhage should be closely
monitored for the first three months and PPV is
advised mostly in cases of non-clearing VH
[25].
In conclusion, VH is a common reason of
painless unilateral visual worsening which can
be irreversible. US has proven to be an effective
diagnostic tool, which helped to identify VH
caused by retinal tears and determine the
urgency of surgical intervention. PPV has
shown to be the main treatment method for
dense VH caused by retinal tears with minimal
complications risk and promising outcomes.
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