January 13, 2022
Authored by: Danielle Strauss, MD
CC: 78 yo hispanic woman with acute decrease in vision OD for 3 days. No pain.
PMHX: Past medical history of hypertension, type 2 diabetes, stroke on Xarelto
Past ocular history: Cataract extraction with IOL implantation both eyes
Va sc: LP OD, 20/25 OS
IOP: 45 OD, 12 OS
1-2+ Corneal edema od
No rubeosis ou
DFE: OD: No view to the posterior pole
The patient has a dense vitreous hemorrhage in the right eye with a hyphema and elevated iop. Ultrasound of the right eye confirms dense vitreous hemorrhage but shows the retina to be attached.
The differential diagnosis for vitreous hemorrhage of unclear etiology in a 78 year-old includes proliferative diabetic retinopathy (PDR), ischemic retinal vein occlusion (BRVO or CRVO) with retinal neovascularization, hemorrhagic PVD with or without a retinal tear, UGH syndrome, other retinal neovascular processes including sickle cell retinopathy. Anticoagulant medications are not thought to cause spontaneous vitreous hemorrhages, especially the newer, and more widely used medications such as Xarelto and Eliquis.
In this case, the patient had a medical history of diabetes, however the left eye did not have any findings of diabetic retinopathy so possible PDR was not likely the cause of the bleed. The patient did have a hyphema with secondary IOP elevation and corneal edema, but no evidence of rubeosis. Given the patient’s medical history we suspected possible vein occlusion given the ipsilateral process.
Since the retina appeared to be attached on bscan, emergent surgery was not necessary. Rather, we planned to treat the iop elevation and corneal edema to optimize the anterior segment prior to any retinal surgical intervention.
Assessment and plan:
Vitreous hemorrhage of unclear etiology right eye
Hyphema right eye with secondary IOP elevation and corneal edema
Plan: Start IOP lowering medications and topical steroid, plan a pars plana vitrectomy and washout of the anterior chamber.
The patient returned the next day and the iop was reduced to 17mm Hg.
The corneal edema was clearing. Vision remained LP with no evidence of clearing of the vitreous hemorrhage. We decided to proceed with the surgery.
The patient had a pars plana vitrectomy with removal of the hyphema.
Intraoperatively, the hyphema was removed from the anterior chamber. It was noted, again, that there was no evidence of rubeosis. The cause of the hyphema was red blood cells from the vitreous that had migrated to the anterior chamber through an area of zonular weakness. Next, a pars plana vitrectomy was performed and the dense vitreous hemorrhage was removed. Inspection of the fundus revealed a large retinal tear with a bridging vessel supero-temporally. There was no clinical retinal detachment, but there was early subretinal fluid surrounding the tear. The bridging vessel was cauterized and the tear and early RD were treated with laser.
Post-operatively, the patient’s vision improved from LP to 20/25. The IOP was normal and there was no evidence of re-bleeding. The patient was grateful we had intervened to save her vision.
Post-operative color photos and OCT:
Vitreous hemorrhage due to retinal tear with bridging vessel.