Pediatric Vitreous Hemorrhage: A Parent’s Guide
Understanding Vitreous Hemorrhage in Children
The vitreous is a clear, jelly-like substance that fills the space between the lens at the front of the eye and the retina at the back. When blood vessels inside the eye break or leak, blood can collect in this space. This is called vitreous hemorrhage.
In children, this bleeding can partially or completely block vision. Because a child's visual system is still maturing, even a temporary loss of clear vision can lead to amblyopia (sometimes called lazy eye). In amblyopia, the brain stops developing normal vision in the affected eye. This makes early diagnosis and treatment especially important for younger children.
Vitreous hemorrhage in children presents unique challenges. Children may not be able to describe their symptoms clearly. Young children in particular may not tell a parent that they cannot see well out of one eye. Doctors may also find it difficult to examine a child who cannot sit still or cooperate during an eye exam.
The causes of vitreous hemorrhage also differ between children and adults. In adults, diabetes and age-related conditions are the most common triggers. In children, trauma is the leading cause, and several rare childhood conditions can also play a role. Treatment planning must account for the risks of general anesthesia and the difficulty of keeping a child in a specific position after surgery. There is also an urgent need to restore clear vision to prevent amblyopia.
Blood can enter the vitreous through several mechanisms. Direct injury to the eye can rupture normal, healthy blood vessels. In other cases, certain diseases cause the retina to receive too little oxygen. The body then releases vascular endothelial growth factor (VEGF) and other chemical signals. These signals trigger the growth of new blood vessels that are fragile and prone to spontaneous bleeding.
In some children, vitreous hemorrhage results from a persistent hyaloid artery. This is a blood vessel that normally disappears before birth but occasionally remains. A retina specialist can sometimes see this vessel during a dilated eye exam.
Who Is Affected and Risk Factors
Trauma is by far the most common reason children develop vitreous hemorrhage. In a study of 230 patients (240 eyes) aged 16 years or younger, traumatic vitreous hemorrhage accounted for 82.5% of cases (PMC, Rishi et al., 2014). Blunt injuries, such as those from a ball, fist, or fall, made up about a substantial proportion of trauma cases (PMC, Rishi et al., 2014). Penetrating injuries from sharp objects accounted for about a substantial proportion (PMC, Rishi et al., 2014).
Parents should be aware that any significant blow to the eye or head can cause bleeding inside the eye. This is true even if there is no visible injury on the outside.
When trauma is not involved, common causes of pediatric vitreous hemorrhage include vasculitis (inflammation of blood vessels) and hematologic (blood) disorders. Vasculitis accounts for about 34.6% of spontaneous cases, and blood disorders account for about 27.4% (PMC, Rishi et al., 2014). Other non-traumatic causes include:
- Retinopathy of prematurity (abnormal blood vessel growth in premature infants)
- Sickle cell retinopathy (a complication of sickle cell disease)
- Juvenile-onset diabetes and diabetic retinopathy
- Persistent fetal vasculature (blood vessels from fetal development that did not dissolve)
- Intermediate uveitis and pars planitis (types of eye inflammation)
Research has identified several factors that increase the risk of severe visual loss in children with vitreous hemorrhage. These include male sex, age greater than 8 years, involvement of only one eye, and need for surgical treatment (PMC, Rishi et al., 2014).
Younger age at diagnosis has been shown to be a risk factor for vitreous hemorrhage in children with intermediate uveitis. Children with pars planitis have a higher prevalence of vitreous hemorrhage (28%) compared to adults with the same condition (6%), a statistically significant difference (P = 0.003) (Donaldson et al., 2002).
Vitreous hemorrhage can be a sign of abusive head trauma, sometimes called shaken-baby syndrome. In one study, shaken-baby syndrome accounted for 8.6% of pediatric vitreous hemorrhage cases (PMC, Rishi et al., 2014). Other eye findings associated with abusive head trauma include retinal folds, macular retinoschisis (splitting of retinal layers at the macula), and papilledema (swelling of the optic nerve).
If a child, especially an infant, presents with vitreous hemorrhage and no clear history of accidental trauma, a retina specialist and pediatrician will carefully evaluate for possible abuse. This is a critical part of protecting the child's safety.
Signs Parents Should Watch For
The symptoms of vitreous hemorrhage in children can be difficult to detect. This is especially true for infants and toddlers who cannot describe what they see. Older children may complain of decreased vision, floaters, cobwebs, shadows, or a reddish haze. In a study of pediatric cases, diminished vision was the presenting complaint in 96.45% of patients (PMC, Rishi et al., 2014).
Parents may notice that their child is squinting, covering one eye, bumping into objects on one side, or showing less interest in activities that require good vision. Irritability or behavioral changes in a young child may be an important clue.
Children with vitreous hemorrhage often report that their vision is worse in the morning. This happens because blood settles to the back of the eye overnight. It covers the macula, the part of the retina responsible for central, detailed vision. As the child moves around during the day, the blood may shift and vision may improve somewhat.
A more significant hemorrhage can severely limit visual acuity and visual fields. It may also cause scotomas (blind spots). If your child suddenly reports a large dark area in their vision or a dramatic drop in sight, this warrants immediate evaluation.
Certain symptoms require urgent action. See a retina specialist or go to the emergency room immediately if your child experiences any of the following:
- Sudden increase in floaters or new dark spots in vision
- Flashes of light in one eye
- A curtain, shadow, or dark area spreading across the vision
- Sudden, significant vision loss in one eye
These symptoms may indicate a retinal tear or retinal detachment. Prompt treatment can make a meaningful difference in preserving your child's vision.
How It Is Diagnosed
Diagnosing vitreous hemorrhage in children can be challenging. Young children may not cooperate with standard eye exams, and infants cannot describe their symptoms. A retina specialist will begin with a thorough dilated eye exam. Special drops are used to widen the pupil and examine the inside of the eye.
If the hemorrhage is mild, the specialist may be able to see through the blood to evaluate the retina. If the bleeding is dense, it may block the view entirely, and additional imaging will be needed.
When blood inside the eye prevents a clear view of the retina, B-scan ultrasonography (an ultrasound of the eye) is one of the most important tools available. This painless test uses sound waves to create a picture of the structures inside the eye. It can reveal whether a retinal detachment, retinal tear, tumor, or foreign body is present.
Ultrasound is especially valuable in pediatric cases. It does not require radiation and can often be performed even in young children with minimal cooperation.
Optical coherence tomography (OCT) is a non-invasive scan that creates detailed cross-sectional images of the retina. In some cases of abusive head trauma, OCT can reveal findings not visible on a standard exam.
Optical coherence tomography angiography (OCT-A) is a newer technology that maps blood flow in the retina without the need for dye injections. OCT-A has been used to identify blood flow through otherwise hidden remnants of the hyaloid artery. This technology may help explain previously unexplained cases of pediatric vitreous hemorrhage.
Non-traumatic vitreous hemorrhage in children can be linked to blood disorders, inflammatory diseases, and other systemic conditions. A retina specialist may request blood tests to check for clotting disorders, sickle cell disease, diabetes, and markers of inflammation. In cases where abuse is suspected, a full medical and social evaluation will also be performed.
Treatment Options
Not every case of pediatric vitreous hemorrhage requires surgery. In a study of pediatric cases, observation was the most common initial approach, used in about 50% of cases. About 23.3% of eyes did not require any intervention at all (PMC, Rishi et al., 2014). When the hemorrhage is mild and the retina appears healthy, a retina specialist may recommend close monitoring.
Medical therapy may include topical eye drops or systemic (whole-body) medications to address the underlying cause. Anti-inflammatory drugs for uveitis or treatments for blood disorders are examples.
Laser photocoagulation (a thermal laser treatment applied to the retina) was used in about 29% of pediatric vitreous hemorrhage cases in one study (PMC, Rishi et al., 2014). This treatment is often used when abnormal blood vessels are the source of bleeding. The laser seals leaking vessels or destroys areas of oxygen-deprived retina.
Laser treatment can sometimes be performed in the office for older, cooperative children. Younger children may require sedation or general anesthesia.
Vitrectomy (a surgery to remove the gel inside the eye along with the blood) was the most common surgical procedure, performed in about 45.7% of cases (PMC, Rishi et al., 2014). A retina specialist may recommend earlier surgery in several situations:
- Children in the amblyogenic age range (typically under 7 to 8 years), where prolonged vision loss can cause lasting visual development problems
- Children with juvenile-onset diabetes
- Bilateral vitreous hemorrhage (both eyes affected)
- Suspected retinal traction or retinal detachment behind the hemorrhage
In children with massive vitreous hemorrhage from Terson syndrome (bleeding inside the eye associated with bleeding around the brain), vitrectomy has been shown to be effective. Earlier surgery helps prevent amblyopia and complications from prolonged contact between blood and retinal tissue.
In some cases involving abnormal blood vessel growth, a retina specialist may consider anti-VEGF injections. Research in adults suggests that using anti-VEGF medication before vitrectomy in diabetic cases can lower the rate of early postoperative bleeding (Smith and Steel, 2015). Medications such as Avastin (bevacizumab), which is FDA-approved for cancer and used off-label for eye conditions, or Lucentis (ranibizumab) may be considered.
The use of anti-VEGF injections in children is evaluated on a case-by-case basis. A retina specialist will weigh the potential benefits against the risks. This includes the theoretical concern about systemic VEGF suppression in a growing child.
What to Expect for Your Child
If your child needs surgery, the retina specialist will explain the procedure and what to expect. Most pediatric vitrectomies are performed under general anesthesia. The surgical team will discuss the anesthesia risks with you beforehand. The surgery itself typically takes one to two hours, depending on the complexity of the case.
If a gas or silicone oil tamponade (a bubble placed inside the eye to hold the retina in place) is used, your child may need to maintain a specific head position after surgery. This can be challenging with young children and will require patience from parents and caregivers.
Recovery time varies depending on the cause and severity of the hemorrhage and the type of treatment. After vitrectomy, your child will need several follow-up visits with a retina specialist. These appointments allow the specialist to monitor healing, check for recurrent bleeding, and watch for complications.
Your child may need to avoid strenuous activities, contact sports, and swimming for a period of time. Eye drops to prevent infection and reduce inflammation are typically prescribed for several weeks after surgery.
Restoring clear vision is only the first step. If your child's vision was blocked for a significant period, especially during early childhood, amblyopia may develop. The retina specialist may work with a pediatric ophthalmologist to manage this through patching therapy (covering the stronger eye) or corrective lenses.
Ensuring your child has the right glasses or contact lens prescription is an important part of long-term care. Regular vision assessments help ensure your child's visual development stays on track.
Long-Term Outlook
Because trauma is the leading cause of vitreous hemorrhage in children, prevention is a key priority. Protective eyewear should be worn during sports and any activity that poses a risk of eye injury. Polycarbonate sport goggles or glasses with shatter-resistant lenses provide strong protection.
For children with conditions that increase the risk of recurrent bleeding, careful management of the systemic condition is essential. Keeping blood sugar well controlled in a child with diabetes, for example, can reduce the risk of diabetic retinopathy.
Vision problems and medical procedures can be frightening for a child. Age-appropriate explanations of what is happening can reduce anxiety. Many children benefit from meeting the surgical team before a procedure and having a comfort item with them during hospital visits.
Watch for signs of stress, such as changes in sleep, appetite, or behavior. Consider speaking with a child psychologist if your child is having difficulty coping.
Children who have experienced vitreous hemorrhage need ongoing eye care, even after the initial episode has resolved. The frequency of follow-up visits depends on the underlying cause. Children with inflammatory conditions, blood disorders, or diabetes will need regular retinal exams throughout childhood and into adulthood.
Even after successful treatment, there is a risk of recurrence. Keeping all scheduled appointments and promptly reporting any new visual symptoms are the most important steps you can take.
Questions and Answers
Visual outcomes depend on the cause and severity of the hemorrhage, whether the retina was damaged, and how quickly treatment was started. Many children do regain functional vision, especially when the hemorrhage clears or is removed before amblyopia develops. However, if the retina was injured by trauma or an underlying disease, some lasting vision loss may occur. A retina specialist can give you a more specific outlook based on your child's individual situation.
Babies cannot tell you they are having trouble seeing. Watch for signs such as not tracking objects with one eye, not making eye contact, or turning the head in an unusual way. A white or unusual reflection in the pupil, visible in photographs or in certain lighting, should prompt an immediate eye exam. If your baby has experienced head trauma, request an urgent evaluation by a pediatric ophthalmologist or retina specialist.
Vitrectomy in children does carry risks, including those associated with general anesthesia. However, modern surgical techniques and anesthesia protocols have made these procedures much safer. In many cases, the risk of not operating, particularly the risk of amblyopia from prolonged vision loss, outweighs the surgical risks. A retina specialist will discuss the specific risks and benefits with you before recommending surgery.
If your child receives a significant blow to the eye, do not press on the eye or attempt to examine it yourself. Apply a protective shield, such as the bottom of a paper cup taped over the eye, to prevent further pressure. Take your child to an emergency room or a retina specialist as soon as possible. Even if the eye looks normal from the outside, internal bleeding or retinal damage may have occurred.
In many cases, yes. If an underlying condition such as uveitis, sickle cell disease, or diabetes caused the hemorrhage, that condition will need continued management. Children treated for vitreous hemorrhage also need regular follow-up eye exams. Your retina specialist will create a long-term monitoring plan tailored to your child's needs.