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Vitreous Hemorrhage: Causes, Symptoms, and Treatment
What Is Vitreous Hemorrhage?
Vitreous hemorrhage occurs when blood enters the vitreous cavity, the clear gel-filled space that makes up most of the eye's interior. When blood is present in this space, it disrupts the passage of light to the retina and causes sudden, often dramatic changes in vision.
The vitreous is a transparent gel that fills the back two-thirds of the eye. In a healthy eye, it is completely clear, allowing light to pass through without interference and reach the retina, the thin layer of light-sensitive tissue at the back of the eye. The retina then converts that light into signals the brain interprets as images.
Because the vitreous has no blood vessels of its own, any blood that enters this space comes from elsewhere, most often from the retina or nearby structures.
Blood can reach the vitreous through several pathways. Normal retinal blood vessels can rupture when the vitreous gel pulls on them during a process called posterior vitreous detachment. Abnormal new blood vessels that have grown in response to disease can break and bleed spontaneously. In some cases, blood from adjacent structures can seep into the vitreous space as well.
In conditions like diabetic retinopathy, the retina does not receive adequate oxygen and releases a protein called vascular endothelial growth factor, or VEGF. VEGF stimulates the growth of new blood vessels on the retinal surface. These vessels are structurally fragile and lack the tight cellular connections found in healthy vessels, making them prone to rupturing without warning.
When blood enters the vitreous, it initially forms small clots. Over time, the body slowly absorbs the blood through natural processes. A mild hemorrhage may clear in a matter of weeks, while a significant bleed can take months to resolve on its own.
During this clearing period, the blood blocks or scatters incoming light, which is what causes the vision disturbances patients experience. Fortunately, the body's absorption process produces very little inflammation, helping to limit additional damage to surrounding retinal tissue.
Who Is at Risk for Vitreous Hemorrhage?
Vitreous hemorrhage can affect people at any age, though the most common causes differ between younger and older patients. Certain medical conditions and lifestyle factors substantially increase the risk.
Vitreous hemorrhage is estimated to affect roughly 7 out of every 100,000 people in the United States each year. It is among the most frequent causes of acute, painless vision loss and is a common reason for urgent referral to a retina specialist.
Proliferative diabetic retinopathy (PDR) is the leading cause of vitreous hemorrhage in adults, accounting for a large proportion of all diagnosed cases. In PDR, chronically elevated blood sugar damages the small blood vessels supplying the retina. The eye responds by generating new, abnormal blood vessels through the VEGF pathway. These fragile vessels are highly prone to rupturing and can bleed without any physical trigger or warning.
Poor blood sugar control substantially increases this risk. Patients with diabetes should be especially alert to any sudden change in vision and contact a retina specialist without delay.
As part of normal aging, the vitreous gel gradually shrinks and pulls away from the retina, a process known as posterior vitreous detachment (PVD). PVD becomes increasingly common after age 60. As the vitreous separates, it can tug on retinal blood vessels and cause them to tear and bleed into the vitreous space.
PVD-related vitreous hemorrhage also carries a significant risk of a concurrent retinal tear, making prompt evaluation critical. Flashes of light and a sudden increase in floaters in someone over 50 always warrant same-day or next-day examination.
Eye trauma is the leading cause of vitreous hemorrhage in patients under 40, and males are disproportionately affected in this category. A direct blow to the eye or head can rupture retinal blood vessels and cause immediate bleeding into the vitreous.
Other conditions that can cause vitreous hemorrhage include:
- Retinal vein occlusion, a blockage in the veins that drain the retina
- Age-related macular degeneration with abnormal blood vessel growth beneath the retina
- Sickle cell disease, particularly in Black patients, where abnormal red blood cells damage small retinal vessels
- High myopia (severe nearsightedness), which stretches and thins the retinal tissue
- Retinopathy of prematurity in infants born very early
Several other factors can increase the likelihood of vitreous hemorrhage or worsen existing bleeding. Previous cataract surgery can alter the structure of the vitreous and increase the risk of PVD. Use of blood-thinning medications or underlying clotting disorders can prolong or intensify hemorrhage once it starts. High blood pressure (hypertension) and atherosclerosis (hardening of the arteries) can weaken retinal vessel walls over time, increasing the risk of rupture.
Recognizing the Symptoms
The symptoms of vitreous hemorrhage range in severity depending on how much blood has entered the eye and where it has settled. Some patients notice only minor visual disturbances, while others experience a sudden and dramatic drop in vision.
The defining characteristic of vitreous hemorrhage is a sudden, painless change in vision in one eye. A small bleed may produce only a few new floaters or a faint haze across the visual field. A large hemorrhage can reduce vision to the point where a person can only detect hand movement or distinguish light from dark.
The absence of pain is one feature that distinguishes vitreous hemorrhage from some other acute eye conditions, and it is part of why the experience can feel disorienting or unexpected.
Many patients first notice new floaters appearing as dark streaks, cobwebs, spots, or shadowy clouds drifting across their field of vision. Some people describe a reddish or brownish tint to their vision caused by the presence of blood. Vision may appear worse in the morning because blood settles over the macula (the central portion of the retina responsible for sharp, detailed vision) during sleep. After standing or sitting upright, the blood may shift and vision may temporarily seem to improve.
Flashes of light alongside new floaters can signal that the vitreous is pulling on the retina, which may indicate a retinal tear or early retinal detachment. A dark shadow or curtain appearing at the edge of the visual field and closing inward is a particularly urgent sign. Seek immediate evaluation if you experience any of the following:
- A sudden, significant drop in vision in one eye
- A flood of new floaters, particularly dark streaks or cobweb-like shapes
- Flashes of light in one eye, especially when accompanied by new floaters
- A dark shadow or curtain appearing to close in from any direction
- A red or brownish tint to your vision that appears suddenly
How We Diagnose Vitreous Hemorrhage
Accurate diagnosis requires a thorough examination by a retina specialist, often supported by imaging that can see beyond the blood obscuring the retina. Identifying the source and underlying cause of the hemorrhage is essential to selecting the right treatment.
A retina specialist begins with a dilated eye exam, in which drops are used to widen the pupil and allow a detailed view of the vitreous and retina. Using a specialized microscope and lens, the doctor can assess the density of the hemorrhage, locate the source of bleeding, and evaluate any retinal tissue that remains visible.
In mild hemorrhages, the retina may be partially visible and the source of bleeding may be identifiable. In dense hemorrhages, blood can obscure the entire retinal view, requiring additional imaging tools.
When blood is too dense to see through, a B-scan ultrasound is used. This quick, painless test uses sound waves to create a detailed image of the eye's internal structures even when the view is completely blocked by blood. It can reveal whether the retina is still attached, whether a retinal tear is present, and whether other abnormalities such as a tumor or tractional tissue are visible.
B-scan ultrasonography is an essential part of the retinal evaluation whenever a hemorrhage prevents direct examination of the retina.
In mild to moderate hemorrhages where some view of the retina is preserved, optical coherence tomography (OCT) provides high-resolution cross-sectional images of the retinal layers. OCT can identify macular swelling, structural damage, or tractional forces on the retina. Widefield imaging systems photograph a broad area of the retinal periphery, helping to identify abnormal blood vessels, small tears, or areas of poor retinal circulation that may be contributing to the hemorrhage.
When the cause of the hemorrhage is not immediately apparent from the eye examination, blood tests may be ordered to check for diabetes, clotting disorders, or sickle cell disease. A thorough review of medical history helps identify contributing factors such as use of blood-thinning medications, high blood pressure, or a history of previous eye surgery or trauma.
Treatment Options for Vitreous Hemorrhage
Treatment depends on the severity of the hemorrhage, its underlying cause, and whether the retina has been damaged. Options range from careful monitoring to surgery, and a combination of approaches is often used based on individual patient factors.
For mild hemorrhages without a retinal tear or condition requiring immediate intervention, a watchful waiting approach may be appropriate. Small bleeds often resolve naturally as the body absorbs the blood over several weeks. During this period, your retina specialist will schedule regular follow-up appointments to monitor the clearing of blood and check for any retinal complications.
Patients are typically advised to keep their head elevated, especially during sleep, to encourage blood to settle away from the central visual axis. This can help preserve functional central vision while the hemorrhage gradually clears.
For vitreous hemorrhage caused by proliferative diabetic retinopathy, anti-VEGF injections are an effective treatment option. These medications are administered directly into the eye and work by blocking the VEGF protein that drives abnormal blood vessel growth. Reducing VEGF activity causes the abnormal vessels to shrink, stopping active bleeding and lowering the risk of future hemorrhage.
Anti-VEGF therapy may be used as a primary treatment or as preparation for surgery. Clinical research has shown that this approach can produce visual outcomes comparable to surgery combined with laser treatment in many patients with diabetic vitreous hemorrhage, though surgery tends to result in faster initial visual recovery. The frequency and number of injections are determined by your retina specialist based on how your eye responds over time.
Pars plana vitrectomy is a surgical procedure in which the vitreous gel and the blood within it are removed from the eye. A retina specialist performs this using small, precisely designed instruments inserted through tiny incisions in the wall of the eye. Modern small-gauge vitrectomy systems have significantly reduced surgical trauma and shortened recovery time compared to earlier techniques.
Vitrectomy is recommended when a hemorrhage does not clear on its own, when the blood is too dense to allow examination or treatment of the retina, or when a retinal tear or detachment is present. During the same procedure, the surgeon can repair retinal tears, remove fibrous scar tissue, and apply laser treatment to address the underlying cause of the bleeding.
When a retinal tear or break is identified, laser photocoagulation (a thermal laser that bonds the retina to the underlying tissue) or cryopexy (a controlled freezing treatment that seals the retina) is used to prevent the tear from progressing to a full retinal detachment. These treatments can be performed during vitrectomy or as standalone in-office procedures, depending on the clinical situation.
In cases of proliferative diabetic retinopathy, a more extensive laser treatment called panretinal photocoagulation may be applied to reduce abnormal blood vessel activity across the peripheral retina. This reduces the stimulus for new vessel growth and lowers the risk of future hemorrhage.
Recovery and What to Expect
Recovery from vitreous hemorrhage varies considerably based on the severity of the bleed, its underlying cause, and how it was treated. Understanding the typical timeline and potential complications can help patients feel prepared and know when to reach out to their care team.
With observation alone, a mild hemorrhage may clear over several weeks to a few months, with gradual improvement as the body absorbs the blood. After vitrectomy, many patients notice meaningful visual improvement within the first few weeks, though it can take several additional months to reach the final level of recovery. The extent of vision regained depends largely on whether the retina was damaged by the underlying cause of the hemorrhage. When the retina is structurally intact, the prognosis for visual recovery is generally more favorable.
After vitrectomy, your retina specialist may instruct you to maintain a specific head position for several days. This is necessary when a gas bubble has been placed inside the eye to support the retina during healing. The gas dissolves gradually over one to a few weeks, depending on the type used.
Activity restrictions following vitrectomy typically include avoiding heavy lifting and strenuous exercise for several weeks. Air travel is not permitted while a gas bubble remains in the eye, as changes in cabin pressure can cause the gas to expand and raise intraocular (inside-the-eye) pressure to dangerous levels. Your retina specialist will provide detailed activity guidelines tailored to your specific procedure.
When vitreous hemorrhage is left untreated, several serious complications can develop over time. Ghost cell glaucoma can occur when old, degenerated red blood cells block the eye's drainage system and raise eye pressure. Iron released from blood cells as they break down can become toxic to retinal tissue, a process called hemosiderosis. Persistent blood can also promote the development of fibrous scar tissue that creates traction on the retina.
The most serious complication is retinal detachment, where the retina separates from the back of the eye. This requires urgent surgical repair and carries a higher risk of permanent vision loss the longer it goes unaddressed. Prompt treatment of both the hemorrhage and its underlying cause is the most effective way to prevent these outcomes.
Living Well After Vitreous Hemorrhage
Managing the conditions that contributed to vitreous hemorrhage is just as important as treating the bleeding itself. Long-term eye health often depends on how well underlying conditions are controlled and how consistently patients follow up with their retina specialist.
Because diabetes is the most common cause of vitreous hemorrhage in adults, maintaining good blood sugar control is one of the most meaningful steps a patient can take to reduce the risk of future episodes. Working with a primary care doctor or endocrinologist to keep blood sugar, blood pressure, and cholesterol within healthy ranges supports retinal health over the long term.
Patients with other contributing conditions, such as sickle cell disease, retinal vein occlusion, or hypertension, should work closely with their medical teams to keep these conditions as well controlled as possible.
Patients who have experienced a vitreous hemorrhage are at increased risk for future episodes, particularly when the underlying condition has not been fully resolved. Regular dilated eye exams with a retina specialist are an essential part of long-term care and early detection.
Patients with diabetic retinopathy should follow recommended screening schedules, which typically include at least one dilated exam per year and more frequent visits when active disease is present. Your retina specialist will determine the right monitoring interval based on the severity of your condition.
While vision is impaired, certain daily activities may need to be temporarily modified. Driving should be avoided until vision has recovered sufficiently, and patients should discuss this directly with their retina specialist. Reading and close work can be difficult when the hemorrhage affects central vision, and some patients find magnification aids or large-print materials helpful in the interim.
As vision improves, most patients are able to gradually return to their normal routines. Your retina specialist will provide guidance on safe timelines for resuming specific activities based on your recovery progress.
Frequently Asked Questions
These answers address practical situations and decision points that patients often encounter when managing vitreous hemorrhage, beyond what is covered in the sections above.
Yes, recurrence is possible, and the risk is highest when the underlying cause has not been fully treated. Patients with proliferative diabetic retinopathy are particularly vulnerable to repeat episodes if abnormal blood vessels continue to grow. Completing the full recommended course of anti-VEGF injections, undergoing laser treatment as advised, or proceeding with vitrectomy surgery substantially reduces this risk. Consistent long-term control of blood sugar, blood pressure, and cholesterol is also a meaningful part of preventing recurrence over time.
Not every vitreous hemorrhage requires surgery. Many mild to moderate bleeds without an associated retinal tear or detachment can be managed with careful observation to see whether the blood clears naturally over several weeks. Surgery becomes necessary when the blood does not clear on its own within a reasonable timeframe, when the retina cannot be adequately examined or treated, or when a retinal tear or detachment is present. This decision is always made individually, weighing the cause of the hemorrhage, the condition of the retina, and the impact on your vision and daily functioning.
For most patients with vitreous hemorrhage who have not undergone surgery involving a gas bubble, air travel is generally acceptable. However, if a gas bubble was placed inside your eye during vitrectomy, flying is not safe until that gas has fully dissolved. Changes in cabin pressure at altitude can cause the gas to expand and sharply raise the pressure inside the eye, which can threaten vision. Always inform your retina specialist of any upcoming travel plans so they can advise you based on the current state of your eye and any recent procedures.
Do not stop any prescribed medication without speaking to both your retina specialist and the doctor who prescribed it. Blood-thinning medications, including anticoagulants and antiplatelet agents, are often prescribed to prevent life-threatening conditions such as stroke or heart attack. While these medications can prolong or worsen vitreous bleeding, stopping them abruptly without medical guidance may put you at serious cardiovascular risk. Your retina specialist and your prescribing physician will work together to find the safest approach that accounts for both your eye health and your overall medical needs.
The blood itself does not typically cause permanent damage when it clears from the vitreous, whether naturally or through surgery. However, the condition responsible for the hemorrhage may cause lasting harm to retinal tissue if it goes untreated. A retinal detachment, advanced diabetic retinopathy, or prolonged hemorrhage that leads to iron toxicity in the retina can all result in significant and lasting vision changes. This is why prompt diagnosis and timely treatment of the underlying cause are so important. The earlier care begins, the better the opportunity to preserve useful vision.
Schedule Your Retinal Evaluation
If you are experiencing sudden vision changes, new floaters, flashes of light, or any of the warning signs described on this page, please do not wait to seek evaluation. At New England Retina Associates, our fellowship-trained vitreoretinal surgeons have the expertise, advanced diagnostic tools, and full range of treatment options to accurately diagnose and manage vitreous hemorrhage. We welcome referred patients, self-referred patients, and those with urgent or emergency retinal concerns at our offices throughout Connecticut.
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