Vitreous hemorrhage and its operation
Vitreous hemorrhage, also called vitreous hemorrhage, is bleeding within the vitreous cavity of the eye. The blood spreads into the vitreous gel, the gel that fills the eyeball. Diabetes and retinal tears are the two main causes of vitreous hemorrhage. Symptoms appear suddenly: decreased vision, floaters, or a sensation of red, sooty patches in the vision. Initially, vitreous hemorrhage is monitored. If the blood does not stop flowing quickly, it must be surgically removed. This procedure is called a vitrectomy . It allows the blood to be washed away and the bleeding areas to be cauterized.
What is vitreous hemorrhage?
Vitreous hemorrhage refers to bleeding in the vitreous body, the gel located in contact with the retina at the back of the eye.
This bleeding can be minimal or heavy, resulting in varying degrees of visual disturbances.
Symptoms
Common symptoms of vitreous hemorrhage include:
A blurred vision
Floaters – like soot or cobwebs floating in the field of vision.
A reddish tint to vision.
Photopsias – brief flashes of light in peripheral vision.
Gravity:
A small vitreous hemorrhage often manifests as "floaters".
A moderate case often results in dark streaks in vision.
Massive bleeding significantly impairs vision, even reducing it to simple light perception.
Causes
There are many triggering factors for vitreous hemorrhages.
Diabetic retinopathy – This is the most common cause in adults. Diabetes leads to the formation of abnormal blood vessels at the back of the eye. These new blood vessels are more fragile and tend to rupture, causing bleeding. Diabetic retinopathy accounts for 30 to 50% of vitreous hemorrhage cases in adults in developed countries.
A retinal tear or detachment – A retinal tear can cause a blood vessel on the retina to rupture, resulting in bleeding into the vitreous humor. The presence of a tear also increases the risk of retinal detachment, as fluid seeps under the retina through the tear. Retinal tears account for 10 to 40% of vitreous hemorrhage cases.
Posterior vitreous detachment – Often a trigger for retinal tears, posterior vitreous detachment can nevertheless cause bleeding WITHOUT a tear. In this situation, a small blood vessel in the retina ruptures without the retina itself being severed.
Trauma – Certain injuries can cause bleeding from the blood vessels at the back of the eye. Trauma is the leading cause of vitreous hemorrhage in young people and accounts for 10 to 20% of cases in adults.
Less common causes of vitreous hemorrhage include:
Proliferative sickle cell retinopathy.
Vascular abnormalities, including macroaneurysms.
Macular hematoma in cases of age-related macular degeneration.
Terson syndrome.
Retinal neovascularization resulting from occlusion of a branch or central vein of the retina.
Diagnosis
Vitreous hemorrhage is diagnosed by examining the fundus of the eye after dilating the pupil. The ophthalmologist sees red reflections in the vitreous humor. Depending on the severity of the bleeding, the doctor may be able to observe all or part of the retina, but is usually hampered by the blood present in the vitreous humor.
In the event of significant bleeding, in order to assess the impact of the bleeding on the retina, it is generally recommended to perform an ocular ultrasound to look for a retinal tear or detachment.
Investigate the cause
In cases of vitreous hemorrhage without an obvious cause, an investigation to determine the underlying cause may be carried out. This most often involves blood tests to screen for diabetes and/or sickle cell disease.
Complications
Vitreous hemorrhage is a symptom of an underlying eye condition. These complications are numerous but are generally due to the underlying pathology causing the bleeding. Examples include:
Rhegmatogenous (tear) or tractional (diabetes) retinal detachment.
Neovascular glaucoma.
Macular edema in cases of retinal vein occlusion.
The only complication specific to vitreous hemorrhage is phantom cell glaucoma. This is an open-angle glaucoma caused by degenerated red blood cells that block the eye's pressure regulation system (trabecular meshwork).
Treatment of vitreous hemorrhage
Most often, the bleeding will stop on its own. However, the cause of the bleeding must be treated, and sometimes the blood must be surgically removed by performing a vitrectomy. Treatments for the main causes include:
To cauterize a retinal tear.
Reattaching a detached retina.
Cauterizing new blood vessels in cases of diabetic retinopathy.
Treating a retinal vein occlusion.
In cases of vitreous hemorrhage due to retinal detachment, long-term vitreous hemorrhage (more than 2 or 3 months), or cases associated with iris neoplasm or glaucoma, a vitrectomy may be necessary to remove stagnant blood from the vitreous.
Should blood-thinning medications be stopped in the event of a vitreous hemorrhage?
Yes and no, this choice depends on the benefit/risk balance and the indication for which you have a blood-thinning medication.
Most often, vitreous hemorrhage can be controlled without stopping the medication. In cases of persistent bleeding, temporary discontinuation of the anticoagulant or antiplatelet treatment may be suggested, with the agreement of the specialist who prescribed it.
Medical treatment of vitreous hemorrhage
In the event of vitreous hemorrhage WITHOUT retinal detachment, it is possible to delay any removal of the blood in order to allow it to dissipate and try to cauterize its origin with an argon laser if possible.
This situation is conceivable in cases of vitreous hemorrhage due to retinal tear, diabetic retinopathy and venous occlusion.
In the event of vitreous hemorrhage caused by diabetic retinopathy or venous occlusion, it is possible to resorb the vessels responsible for the bleeding by performing an intravitreal injection of anti-VEGF (a product that rarefies abnormal vessels).
The injection takes place in the office and generally takes 7 to 10 days to take effect.
In cases of vitreous hemorrhage that does not resolve, or in cases of complications such as retinal detachment, surgery is necessary. The procedure is called a vitrectomy. It involves removing the blood-filled vitreous humor before treating the underlying cause. The operation is usually performed as a delayed emergency. The time between the pre-operative consultation and the surgery rarely exceeds one week.
The day of the operation
You will be required to arrive on an empty stomach, having eaten at least 6 hours prior to the time indicated on your summons. Please note: do not consume coffee, tea, food, liquids, or cigarettes.
The procedure typically lasts 45 minutes. However, this time can vary significantly depending on the amount of blood and any surgical difficulties.
The procedure is usually performed on an outpatient basis. You will be able to return home with your companion present the same evening.
Before the operation: the anesthesia consultation
You will see the anesthesiologist in your room or upon arrival at the operating room, as this is an emergency.
For this surgery, regional anesthesia is most often used. You will not be asleep, but you will be completely relaxed.
A closer look at the technique: vitrectomy
Vitreous hemorrhage surgery is usually performed under peribulbar (locoregional) anesthesia. An anesthetic is injected around the eyeball to desensitize and immobilize it.
The major stages of surgery
Vitrectomy – The surgeon cuts and aspirates the blood-filled vitreous humor.
Cauterization – By laser (heat) or cryotherapy (cold), the source of the bleeding is treated.
Tamping – Purified air or gas is injected into the eye at the end of the procedure to dry the retina and promote healing of the bleeding.
Intravitreal injection of anti-VEGF – A product intended to dry out abnormal vessels is injected in cases of diabetes or venous occlusion.
Sutures – Always absorbable, they are rare in cases of gas packing.
Air or gas buffering
At the end of the procedure, an air or gas tamponade is left in your eye. This helps to dry out the source of the bleeding. The tamponade will disappear on its own and be replaced by vitreous humor secreted by your eye. The tamponade lasts approximately:
7 days in case of air tamponade.
3 to 4 weeks in case of gas tamponade.
Tampontion also reduces the risk of postoperative infection and improves the regulation of intraocular pressure.
Positioning
Unlike macular hole and retinal detachment, there is normally no postoperative positioning.
Post-operative care & convalescence
It is recommended to remain calm for at least 15 days after a vitrectomy operation.
The air or gas will dissipate on its own. However, be aware that gas and air are expandable! Travel to high altitudes (mountains, airplanes, etc.) is ABSOLUTELY contraindicated. If you must travel following the operation, speak to your surgeon.
Here's what you should expect after the operation:
Vision will be almost zero after the procedure, as it is impossible to see through the gas.
You will see a clear level appear, then a bubble after a few days.
You may experience some discomfort for a few days to a few weeks after the operation. You will be given pain medication to help you feel better.
The eyelid and conjunctiva may be swollen following the anesthesia; this will disappear within a few days.
You will need to rest and be less active for a few weeks after the operation. Your ophthalmologist will tell you when you can resume exercising, driving, or other activities.
You will need to wear an eye patch at night for one week after the operation. During the day, your regular glasses are sufficient.
You may see floaters and flashes for a few weeks after the procedure.
Your vision should begin to improve about four to six weeks after surgery. It may take months for your vision to stop changing. In addition, your retina may still be healing for three to six months after the operation.
The improvement in your vision depends on the cause of the bleeding. In cases of diabetes or venous occlusion, visual impairment is common.
Risks and complications of the operation
All surgery carries risks of complications. But if you don't treat a vitreous hemorrhage that doesn't resolve on its own, you risk losing your sight and experiencing other complications. Here are the main surgical risks:
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Recurrent bleeding – 5 to 10%, this is the most frequent complication, caused by a new fragility or a new abnormal vessel.
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Cataract – The lens of your eye becomes cloudy following surgery. This is a benign condition.
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Endophthalmitis – A serious infection of the eye.
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Ocular hypertension – Increased pressure in the eye caused by gas and inflammation.
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Macular edema – The operation can cause inflammation of the retina called Irvin Gass, resulting in edema of the macula.
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Pucker – A thin membrane may form on the macula after the operation. If the macula becomes wrinkled, a second operation will be necessary to remove the membrane.
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