Intraocular Hemorrhage

What is Intraocular Hemorrhage?

Intraocular hemorrhage simply means there’s bleeding inside the eye. The eye is made up of different parts that have blood vessels, and bleeding can happen in any of these areas, including the front part of the eye (anterior chamber), the clear, jelly-like substance in the eye (vitreous cavity), light-sensitive layer at the back of the eye (retina), thin layer under the retina that includes blood vessels (choroid), or the area in the back of your eye around the optic nerve. This bleeding can happen due to an injury to the eye, a disease affecting the whole body (systemic illness), or sometimes, it can occur spontaneously, or for no apparent reason.

The type of intraocular hemorrhage is categorized based on where the bleeding is taking place. Here are the common types:

1. Hyphema: This is when blood is found in the front part of the eye, which is known as the anterior chamber. This bleeding can be minimal and only seen under microscopic examination, known as microhyphema.

2. Vitreous Hemorrhage: This occurs when blood is present in and around the front chamber of the eye, and it can further be divided into intragel and preretinal hemorrhages.
– Intragel hemorrhage is when blood is present in the clear jelly substance in the center of the eye. Over time, this kind of bleeding settles downwards, clots, and changes color from bright red to yellow as red blood cells deteriorate.
– Preretinal hemorrhage can also occur in two forms:
– Subhyaloid hemorrhage is found behind a thin layer on the back of the eye. The location of this type of bleeding may shift with eye movement, especially in those with proliferative diabetic retinopathy, a type of eye disease experienced by people with diabetes.
– Sub-ILM hemorrhage is bleeding between layers of the retina and nerve fibers and usually remains stationary. It often appears in specific conditions like Valsalva retinopathy, Terson syndrome, and retinal microaneurysm.

3. Suprachoroidal hemorrhage: It refers to bleeding due to rupture of blood vessels between the choroid and eye lining (sclera). Commonly, this occurs during or after an eye operation, because of trauma, and on rare occasions, it can happen spontaneously.

4. Retinal Hemorrhages: These Haemorrhages are key indicators of vascular abnormalities and should be extensively investigated. They can take place in different parts and layers of the retina.

5. Disc Hemorrhage: Also called Drance hemorrhage, these are linear bleeds perpendicular to the optic nerve head, usually observed at the top or bottom margin of the nerve.

And finally, submacular hemorrhage should be mentioned separately as it directly impacts vision quality. This refers to bleeding directly below the macula, an area in the center of the retina that helps in sharp, detailed vision.

What Causes Intraocular Hemorrhage?

Intraocular hemorrhage, or bleeding inside the eye, can happen for a variety of reasons. Some are related to overall health and some are connected directly to the eye itself.

Main health-related causes include conditions like diabetes and high blood pressure, physical injury, blood abnormalities, disorders affecting blood clotting, shaken baby syndrome, certain types of eye damage like Purtscher retinopathy or Terson syndrome, a head injury, strain from coughing or heavy lifting (Valsalva maneuver), certain medications and conditions causing low iron or abnormal red blood cells.

Eye-specific causes include eye injury, effects of diabetes on the eye, small ballooning sections of blood vessels in the eye (arterial microaneurysm), tearing of the eye’s retina, issues affecting blood flow in the eye’s veins, severe low pressure inside the eye, and complications from any eye surgery.

There are several types of intraocular hemorrhage. Hyphema, for example, can occur due to injuries, after eye surgery, bleeding from new blood vessels growing on the iris – which is often a result of a severe form of diabetic eye disease. Also, virus-caused inflammation of the eye — herpetic keratouveitis — can result in this issue.

Vitreous hemorrhage, or bleeding inside the gel-like substance that fills the eye, can occur due to conditions that cause changes in the walls of blood vessels in the eye or changes in the blood itself. It might occur as a result of tension on a blood vessel, reduced blood supply that leads to the growth of new, fragile blood vessels, or spontaneously in rare instances. Traumas, diabetic retinopathy, inflammation of the blood vessels in the eye (vasculitis), certain forms of age-related macular degeneration (wet AMD), and others conditions might lead to vitreous hemorrhages.

Retinal and macular hemorrhages are related to conditions like diabetic retinopathy, high blood pressure, blockages in the retinal veins, wet AMD, and others.

Suprachoroidal hemorrhage can happen as a result of conditions like glaucoma, absence of the eye’s natural lens (aphakia), high internal eye pressure before surgery, previous eye procedures or traumatic events, etc.

The exact causes for optic disc hemorrhage, or bleeding of the optic disc, are still debated among experts. It’s believed to occur either due to mechanical stress near a part of the optic nerve head known as the lamina cribrosa or due to tiny areas of inadequate blood supply in the optic nerve head caused by glaucoma or other non-glaucoma-related causes.

Risk Factors and Frequency for Intraocular Hemorrhage

Eye injuries can cause damaged blood vessels to bleed in the eye. These occurrences can happen at any age and aren’t more common in one gender versus another. Still, young males typically have more of these injuries, likely due to outdoor activities and intense labor. The frequency of these injuries tends to increase in children during the summer months when they participate in more outdoor activities.

• Eye injuries that lead to bleeding, known as traumatic hyphemas, occur in about 12 out of every 100,000 people.
• Boys and men are three to five times more likely to experience this than girls and women.
• About 70% of these injuries occur in children, particularly those between the ages of 10 and 20.
• In some cases of vitreous hemorrhage, or bleeding into a part of the eye, 34.1% had diabetes-related eye disease, 22.4% had retinal tears with an intact retina, 14.9% had detached retinas, and 13% had blocked retinal veins. The remaining 16% of cases had other conditions, such as a detached posterior vitreous, retinal inflammation, sickle cell disease-related eye disease, age-related macular degeneration, cancer, premature retinopathy, leukemia, acute retinal death, HIV-related retinopathy, or rarely, uveitis.
• The chances of having a bleed in the eye are directly related to the presence of conditions that could increase the risk of bleeding.
• Suprachoroidal hemorrhage, bleeding on a layer of the eye, occurs in 0.29% of all eye surgeries.
• Submacular hemorrhage, or bleeding under the retina, occurs at a rate of 5.4 per million per year. Over half of these cases had a history of age-related macular degeneration.
• Shaken baby syndrome, a form of child abuse that can result in eye bleeding, affects between 15 and 30 in every 100,000 children under the age of one.

Signs and Symptoms of Intraocular Hemorrhage

When dealing with a patient who has experienced eye trauma or associated symptoms, it’s important to ask about their medical history. Find out when the symptoms started and how they’ve progressed. Ask about any injury associated with traffic accidents, physical assault, or chest compression. Look into any history of diseases such as diabetes, hypertension, or disorders related to metabolism, bleeding, coagulation, kidney, or heart. Additionally, inquire about any medications they’ve been taking recently.

Patients with a particular condition called ‘macular hemorrhage’ might also report additional symptoms like central blind spots (scotoma), changes in the shape or size of objects (metamorphopsia, micropsia), and a loss of color or contrast. These elements should all be asked about as well.

After getting the patient’s history, a careful eye examination should be conducted. One of the tools used for this is a ‘slit-lamp’, which helps determine the severity of bleeding and any associated complications.

Based on this examination, a condition called ‘hyphema’ (blood in the anterior eye chamber) can be classified into four grades:

• Grade 0: Microhyphema (Red Blood Cells scattered in the anterior chamber)
• Grade I: Less than 1/3rd of the anterior chamber is filled with blood
• Grade II: 1/3 to 1/2 of the anterior chamber is filled with blood
• Grade III: More than 1/2 but less than the total of the anterior chamber is filled with blood
• Grade IV: The entire anterior chamber is filled with fresh blood (total hyphema)

After this, eye pressure should be tracked. Techniques like gonioscopy should be performed to check for injuries to the iris and the part of the eye where fluid drains out (angle recession). It’s also crucial to check the responses of the pupil to light, and a detailed examination of the back parts of the eye should be done by dilating the pupil.

If the normal visibility is hampered, an ultrasound (B-scan) of the eye should be performed. This will help rule out additional findings, such as a dislocated lens, presence of foreign bodies, and severe conditions like detached retina or bleeding behind the outer layer of the eyeball (choroid). If a patient has experienced a traumatic injury, a CT scan of the orbit (eye socket) should be done to rule out any fractures, foreign bodies, associated brain injuries.

Additional investigations include devices and methods like Optical Coherence Tomography (OCT), OCT-Angiography, Fluorescein Angiography (FFA), Indocyanine Green Angiography (ICG), and fundus photography. These methods help to locate the cause of internal bleeding inside the eye.

Macular hemorrhage patients should also be asked about elements like blind spots, and changes in the shape or size of objects.

For hyphema patients and those with iris abnormalities, gonioscopy should be performed to rule out any angle recession.

Suprachoroidal hemorrhage, which usually appears during or after an operation, can also be a concern:

• In cataract surgery, it mostly happens during the operation.
• In glaucoma surgery, it mostly occurs after the operation.
• symptoms include severe pain, nausea, vomiting, and decreased vision after the surgery.
• Signs can include loss of the red reflex, sudden increase in eye pressure, physical changes in the eye, and in some cases, parts of the eye being expelled from the wound.

Testing for Intraocular Hemorrhage

If you have hyphema, which is bleeding in the front of your eye, your doctor can find this through an examination using a machine called a slit-lamp. If the hyphema is a result of an injury, the doctor will also use other tests — like a CT scan to check for an eye injury or a possible fracture around the eye, and an ultrasound to rule out more serious eye problems like internal bleeding, foreign body inside the eye, dislocated lens, or detached retina. The doctor will also check your blood pressure and complete blood count, as well as ask about any blood-thinning medicines you might be taking.

If your doctor suspects you have a vitreous hemorrhage, which is bleeding inside the major, clear part of your eye, they will first check your overall health. They will ask about any underlying conditions you might have that could have caused the hemorrhage, like diabetes, high blood pressure, trauma, or a history of using blood-thinning drugs. They will conduct routine blood tests and if your retina is still more or less visible, they will examine your eye in detail to check the back portion of your eye for any problems.

If your doctor suspects any issues with your macula–the part of your eye responsible for central vision–then they may use a procedure called Optical Coherence Tomography (OCT) to get very detailed images of your eye. Depending on the problem, they might also need to conduct a fluorescein angiography, which is where they photograph the blood vessels in your eye. The doctor may use ultrasound to see the back portion of the eye if your eye’s visibility is an issue.

When checking for a suprachoroidal hemorrhage, which is a severe eye condition where there’s bleeding between layers of your eye, your doctor might be able to diagnose it just by looking. If the internal structure of the eye is too distorted for good visibility, an ultrasound can help by aiding the diagnosis and guiding any necessary surgical treatment. CT scans and MRI can also be very useful for identifying the cause and extent of the bleed.

When your doctor is checking for eye hemorrhages–which are areas of bleeding in the eye–they will use a kind of eye examination where they look inside your eye using a machine that magnifies the image many times. A procedure called OCT can provide more details about the location, size and severity of the bleeding. OCT and another technique called FFA can add more information about the condition of your eye, whether there are new, abnormal blood vessels growing, and how and where the doctor needs to treat these problems.

Treatment Options for Intraocular Hemorrhage

If someone has an eye injury, the first step doctors take is to make sure the rest of the person’s body is stable and safe. Only then do they examine the injured eye closely.

Patients with conditions known as hyphema or vitreous hemorrhage (types of bleeding inside the eye) are advised to sit or recline most of the time. They should also avoid sneezing, coughing, vomiting, and heavy lifting, which can abruptly increase pressure inside the eye and worsen their condition.

Sleeping with the head elevated at around 30 degrees helps to clear the visual line. Spare the eye from excessive activities such as reading, playing, and watching screens. An eye patch can help to rest the eye.

It is important to manage conditions like diabetes, high blood pressure, or any cardiovascular disorder as these can affect eye health. If it’s painful to open the eye for examination, the doctor may use a topical anesthetic (a numbing medicine).

In case of severe pressure increase in the eye, called acute glaucoma, the doctor may consider using medications to reduce it. Some drugs work by blocking specific processes that produce the eye’s fluid, while others increase its outflow or reduce its production. The selection will depend on the individual case and patient’s overall health status.

After ruling out glaucoma, the doctor may prescribe medicine to temporarily paralyze the eye muscles (cycloplegics). This helps with managing pain, reabsorption of blood inside the eye, and prevents additional tear in the blood vessels. Steroid eye drops, in turn, can be helpful to reduce inflammation, accelerates the clearance of the blood, and stabilize the vessels to prevent further bleeding.

In most instances, the hyphema (blood in the front part of the eye) could be managed with the appropriate medical treatment and often does not require a surgical intervention absent other complications such as corneal injury, or raised eye pressure not responding to medication. Special caution is necessary in case of Sickle cell anemia, as the sickle-shaped red blood cells can block eye’s natural drainage pathways, potentially leading to sudden, drastic pressure increase. In such cases, surgical intervention might be required.

When a vitreous hemorrhage is present (bleeding into the jelly-like substance that fills the back part of the eye), it’s necessary to rule out retinal detachment using ultrasound if the retina isn’t visible during examination. As long as the retina is attached, the doctor would usually observe the patient’s condition while conducting required treatment and schedule regular check-ups every one to two weeks.

If the situation deteriorates or preliminary observations reveal specific types of retinopathies, the doctor might consider using procedures like laser treatment, which provokes proliferative retinopathies, or anti-VEGF medication (stops the growth of abnormal blood vessels).

If the hemorrhage does not clear up with these strategies, the doctor might consider a surgery called vitrectomy, where the vitreous humor is removed from the eye to ease the treatment of underlying conditions. This could also apply to traumatized diabetic patients. Prior to the surgery, anti-VEGF medication might be used seven days in advance to reduce bleeding and inflammation.

If there’s a hemorrhage spotted in the layer between the retina and the white of the eye (called subhyaloid), and it doesn’t affect the macula (the part of the eye responsible for our central, sharp vision), it could be observed without further intervention. However, if the macula is involved and results in severe vision loss, a laser treatment is performed to help drain the accumulated blood into the eye’s vitreous cavity, improving vision but potentially increasing floaters.

Suprachoroidal hemorrhage (in the layer between the white of the eye and the highly vascular layer supplying the outer retina) is a serious condition that requires immediate diagnosis and management. If this is detected during a surgery, the procedure should be halted, all wounds closed, and, if necessary, an attempt to drain the accumulated blood should be made to prevent further ocular damage. It’s important to manage the pressure in the eye postoperatively, and medications might be used to decrease inflammation and pain.

If a patient is found to have a hemorrhage in the macula, this is a cause for concern as it can lead to permanent vision loss. The doctor may use anti-VEGF medications, which stops the growth of abnormal blood vessels or other medical treatments. In some cases, a procedure to displace the blood from the macula may be considered. A final option could be macular translocation surgery, which involves moving the macula to a healthier part of the eye, although, this does not generally show promising results.

What else can Intraocular Hemorrhage be?

When looking at the diagnosis of hyphema, which refers to blood in the anterior part (the space between the cornea and the iris) of the eye, there are several conditions physicians might consider. This includes:

• Hyphema caused by eye injury
• Hyphema as a result of eye surgery
• Hyphema associated with herpes keratouveitis
• The syndrome of inflammation of the iris, glaucoma, and hyphema (UGH syndrome)
• Inflammation of the middle layer of the eye (uveitis)
• Bleeding due to iris atrophy in Fuch’s heterochromic iridocyclitis
• Juvenile xanthogranuloma
• Hyphema related to irritation and formation of new blood vessels in iris and angle region due to retinal ischemia, often linked to infections like proliferative diabetic retinopathy, CRVO, or ocular ischemic syndrome

Physicians would also consider other conditions in diagnosing vitreous hemorrhage (bleeding into the vitreous humor of the eye), including:

• Vitritis
• Primary intraocular lymphoma
• Retinoblastoma in children (endophytic)
• Asteroid hyalosis
• Detachment of the retina

For diagnosing retinal hemorrhages or bleeding from the small blood vessels of the retina, doctors consider its occurrence in children and adults. In children, these are generally due to birth trauma, shaken baby syndrome, severe anemia, or health conditions like Coats’ disease, PHPV, or prematurity retinopathy. In adults, the causes could be trauma, diabetes, high blood pressure, eye blood flow blockages, elevated skull pressure or disorders causing abnormal clotting. If ‘Roth’ spots are detected, an extensive systematic evaluation is required to identify their cause.

Disc hemorrhages at the boundary of the optic disc could be due to:

• Posterior vitreous detachment from the disc area
• Restricted blood supply to the optic nerve (ischemic optic neuropathies)
• High-grade hypertensive retinopathy
• Diabetes-related optic nerve damage
• High blood pressure
• Blood cancer (leukemia)
• Lupus (SLE)
• Vascular abnormalities at the disc

Suprachoroidal hemorrhages or bleeding in the space between the outermost layer of the eye and the intermediate vascular layer could be a result of:

• Retrobulbar hemorrhage
• Serum-filled choroidal inflammation (choroidal effusion)
• Bleeding leading to choroidal detachment
• Acute angle-closure glaucoma
• Choroidal abnormalities like choroidal hemangioma
• Posterior scleritis, an inflammation disorder of the white part of the eye

Macular hemorrhage caused by bleeding near the central area of the retina could be due to several reasons:

• Growth of abnormal blood vessels due to old age (choroidal neovascularisation)
• Extreme nearsightedness (high myopia)
• Choroidal rupture due to trauma
• A type of eye inflammation called chorioretinitis
• Damages caused by a laser treatment
• The presence of a foreign body in the eye
• Bursting of tiny blood vessels in the retina due to strain or coughing (Valsalva retinopathy)
• Anemic retinopathy
• Eye effects of leukemia or a secondary eye tumor
• Eye complications from diabetic retinopathy or retinal venous occlusion
• Eye conditions caused by bleeding and clotting disorders.

What to expect with Intraocular Hemorrhage

In simple terms, the outlook for different types of bleeding within the eye, or intraocular hemorrhage, depends on a number of factors. These include where the bleeding occurs, how much bleeding there is, how severe the condition is, and how quickly the blood clears. Other considerations are whether the blood is affecting your ability to see, if there are any additional complications like corneal staining (a condition that stains the front of the eye), retinal detachment (when the retina lifts off the inside back of the eye), pre retinal fibrosis (scar tissue forming on the retina), ischemic optic atrophy (damage to the optic nerve due to poor blood flow), and neovascular glaucoma (a type of glaucoma caused by abnormal blood vessel growth), as well as the impact on a sensitive part of the eye called the macular region.

Hyphema, a pooling of blood in the front of your eye, usually has a good prognosis if it’s not linked with other complications that could threaten your vision. However, more severe cases of hyphema can increase the chances of developing glaucoma and may make normal vision recovery less likely.

One study suggests that blood within the jelly-like substance filling the back of the eye (the vitreous cavity) clears up at a rate of 1% per day.

If you experience a vitreous hemorrhage (bleeding within this jelly-like substance) as a result of the vitreous separating from the retina, the outcome is usually good. The same applies to vitreous hemorrhage or hyphema caused by an injury, but the outlook in these cases largely depends on any associated complications from the injury.

However, conditions like Terson syndrome, anemic retinopathy, and Valsalva retinopathy typically have a relatively positive prognosis.

On the other hand, bleeding due to conditions like wet ARMD (an advanced form of age-related macular degeneration) and PCV (polypoidal choroidal vasculopathy) has a relatively poor prognosis. This is because these conditions can lead to the collection of chronic blood at the macula, causing damage to the layer of the eye responsible for sharp, central vision (photoreceptor layer) and scarring.

Finally, the outlook for a retinal vein occlusion, or a blockage of blood flow in the small veins in the retina, largely depends on the severity of the trigger for the blockage. Similarly, the prognosis for retinal hemorrhages caused by a metabolic disorder or blockages in the retinal veins depends on how successfully the underlying condition is treated. In general, traumatic retinal hemorrhages (caused by injury) have a good prognosis unless the injury also caused a rupture in the layer of blood vessels at the back of the eye (choroidal rupture) involving the macula.

Subhyaloid hemorrhage, bleeding into the area located just behind the vitreous, is associated with a better prognosis if treated early. Vitreous hemorrhage in the additional area of the eye relies heavily on the original vision ability and likelihood of retinal detachment.

The prognosis for disc hemorrhage, or bleeding at the optic disk (where the optic nerve enters the eye), mainly depends on the progression and severity of glaucoma, a condition that damages the optic nerve due to fluid building-up and causing pressure in the eye.

Possible Complications When Diagnosed with Intraocular Hemorrhage

Hyphema, or blood in the eye, can lead to several complications including:

• Rising eye pressure
• Possible rebleeding in the eye
• Staining of the cornea (the front surface of the eye)
• In people with sickle cell anemia, a lack of oxygen in the front chamber of the eye can increase the risk of blockage in the trabecular meshwork (a part of the eye involved in fluid drainage). This is caused by sickled red blood cells and can worsen the condition.

Vitreous hemorrhage, bleeding into the clear, gel-like substance in the back of the eye, can lead to further complications like:

• Epiretinal membrane (a thin layer of tissue forming on the surface of the retina)
• Pigmentary retinopathy (retinal damage due to pigment dispersion)
• Pre-retinal fibrosis or scarring
• Strabismus, a misalignment of the eyes
• Occlusion amblyopia, vision loss in a young person due to obstruction of the visual axis
• Tractional retinal detachment
• Secondary rhegmatogenous retinal detachment
• Neovascular glaucoma, a type of glaucoma caused by abnormal blood vessel growth

Having a supra choroidal hemorrhage, or bleeding between the choroid and sclera layers of the eye, is a severe complication that usually occurs after eye surgery and can make it very difficult for vision recovery despite treatment attempts.

Macular hemorrhages, or bleeding in the center of the retina, could cause:

• Damage to photoreceptor cells, which are light-sensing cells in the retina
• Submacular fibrosis, or scarring beneath the macula
• Retinal neovascularization, abnormal vessel growth due to lack of oxygen
• Vitreoretinal fibrovascular proliferation, abnormal vascular growth in the retina and vitreous
• Chronic collection of blood can lead to macular scarring and sharp vision loss

Preventing Intraocular Hemorrhage

If a patient experiences an internal eye bleed for the first time, it’s important to complete a thorough eye examination to figure out why the bleeding happened. The doctor should explain to the patient what they can expect based on where in the eye the bleed occurred. Soon after this happens, getting a diagnosis and developing a treatment plan are key. They will also need to come back for check-ups at regular intervals. This schedule depends both on where the blood is located in their eye and how serious the condition is.

Establishing good control of conditions like diabetes, high blood pressure, and disorders which affect blood clotting or bleeding is essential to prevent the eye bleed from getting worse. Eye bleeds that occur under the conjunctiva (the clear tissue covering the white part of the eye) or around the eye (black eye) usually get better on their own.

Applying a cold compress might speed up recovery. For a hyphema, which is blood in the front part of the eye, or a vitreous hemorrhage, which is blood in the jelly-like substance that fills the eye, sitting up or reclining can help keep the blood at the bottom of the eye. This position helps to not block the center of vision, thereby reducing issues with sight. Modifying certain lifestyle habits, along with taking prescribed medicines, can help slow down any further bleeding or blood clotting disorders. It’s advised to avoid activities that put extra pressure on the eye when there is an eye bleed present. This means avoiding heavylifting, excessive coughing or sneezing, holding your breath while straining (known as the Valsalva maneuver), high stress levels, and insufficient sleep.

If an internal eye bleed, is affecting a person’s sight and doesn’t improve with medication, surgery may be necessary to fix the issue.