Recurrent Vitreous Hemorrhage After Diabetic Vitrectomy: Why It Happens and What Comes Next
Bleeding Back Into the Eye After Diabetic Vitrectomy: What to Do First
A cloudy or dark eye after diabetic vitrectomy is usually blood, and blood is usually not an emergency. Some things that come with it are. Call your surgeon right away, the same day, if you notice:
- A gray curtain, or a shadow in your side vision.
- Flashing lights that come on all of a sudden.
- Severe eye pain, or a hard, red, aching eye.
- Vision that drops fast over hours, not days.
The Academy lists sudden flashing lights, many new floaters at once, a shadow in the side vision and a gray curtain over part of the field of vision as early signs of a detached retina, and says to call an ophthalmologist immediately if any of them appear.1
Now the calm part. In one review of diabetic vitrectomy, about 89 of every 100 of the bleeds that happened were mild or moderate rather than severe.2 Your surgeon would far rather look at a quiet eye than miss a busy one.
Your surgeon removed the old blood, but the fragile vessels that caused it are still healing. A little fresh bleeding into the space where the gel used to be spreads out and blocks the light.
In a review of 220 eyes that had 25-gauge vitrectomy for proliferative diabetic retinopathy, bleeding came back in 76 of them, about 35 of every 100.2 This is a known part of the road, not a sign the surgery failed.
Call the office and describe what changed and when. Ask whether they want to see you now or at your next booked visit, and say plainly if the eye hurts.
Until you are seen, keep your head up rather than lying flat, and skip heavy lifting and straining. Take your usual drops as prescribed, and do not stop a blood thinner on your own, since that decision belongs to the doctor who prescribed it.
What a Recurrent Vitreous Hemorrhage Actually Is
A vitrectomy removes some or all of the vitreous, the clear gel in the middle of the eye, and replaces it with a saline solution or a gas or oil bubble, and it is used for diabetic retinopathy with bleeding or scar tissue affecting the retina or the gel.3
What surgery cannot remove is the diabetes underneath. The abnormal vessels that bled in the first place are still on or near the retina, and they can leak again while they settle.
The space behind the lens is now mostly fluid, and fluid carries blood everywhere. A few drops disperse into a haze across your whole field, which is why a tiny bleed can feel like a catastrophe.
It also explains why the haze can shift through the day. Loose blood moves with you, so the view is rarely identical from hour to hour, which is unnerving without meaning the eye is getting worse.
Common enough that your surgeon almost certainly discussed it before the operation, even if you do not remember it. In an older series of 315 eyes operated for proliferative diabetic retinopathy, 32 developed bleeding after surgery.4
Across the two studies above the figures run from roughly 1 in 10 eyes to roughly 1 in 3, partly because studies count different things. Some count any trace of blood, others only bleeding heavy enough to blur sight.
Why the Bleeding Comes Back
Bleeding in the first fortnight is by far the most common pattern, and it is the one surgeons expect.
Of the 76 eyes that bled again in the 220-eye review, 46 did so within the first two weeks and 22 more than four weeks after surgery.2 An early bleed and a late one are treated as different questions, because the reasons behind them are not the same.
The vessels of proliferative diabetic retinopathy are thin-walled and leaky, and they do not disappear the moment the gel is removed. If any remain active, particularly on the optic nerve head, they can bleed again.
In the 315-eye series, residual or recurrent new vessels on the optic nerve accounted for 6 of the 32 bleeds.4
Your surgeon worked through a small number of tiny openings in the white of the eye, usually three. In a diabetic eye, tissue can grow into those openings and carry small vessels with it, which then bleed.
Ingrowth of fibrous, vessel-carrying tissue at those entry sites was the single most common reason found in the 315-eye series, accounting for 9 of the 32 bleeds.4 This is one of the reasons a late bleed is looked at differently from an early one.
Panretinal laser calms the signal that drives new vessel growth, and an eye that has not had enough of it stays at risk. Insufficient retinal laser accounted for 7 of the 32 bleeds in that series.4
This one is fixable, which is why more laser is often part of the plan after a rebleed rather than an admission that something went wrong.
Who Is More Likely to Bleed Again
In the 220-eye review, younger age, a higher fasting blood glucose before surgery (an average of 176.7 against 147.7 mg/dL) and a higher diastolic blood pressure at the time of surgery, the lower of the two numbers (an average of 79.2 against 72.8 mm Hg), were each linked with bleeding again.2
These are group patterns from one hospital's records, not a score for your own eye. They point at what is worth working on rather than at what was inevitable.
Both act on the same fragile vessels the surgery was trying to rescue. The Academy's Preferred Practice Pattern notes that keeping blood glucose and blood pressure under control lowers the risk of diabetic retinopathy.5
Nothing about that is fast, and nothing about it undoes a bleed that has already happened. It changes the odds for the months ahead, which is the part still open.
A rebleed is not evidence that you strained too hard, bent over once, or slept the wrong way. It is a known complication of operating on a diabetic eye, and it happens to careful patients and cautious surgeons.
Guilt is worth setting down here, mainly because it delays phone calls. Making the call is the useful part.
What It Looks and Feels Like
Most people describe a sudden crop of dark floaters, cobwebs or smoke, then a haze that thickens. The National Eye Institute describes dark floating spots or streaks that look like cobwebs in the later stages of diabetic retinopathy.6
It is usually painless, and it usually arrives without warning. Your eye will not feel injured, which is exactly why the change is so unsettling.
The blur of the first days after vitrectomy is expected, tends to improve steadily, and often comes with a gritty feeling. The Academy says a scratchy, sandy or gritty sensation is usual after vitrectomy while pain is very rare.3
A rebleed is different: vision that had been improving suddenly gets worse. Direction of travel is the clue worth telling your surgeon about.
Blood in the eye does not usually hurt. Pain, a red eye that feels hard, halos around lights or nausea can point somewhere else, and so can a fixed curtain that stays in the same part of your vision when you move your head.
The Academy tells people with diabetes to call an ophthalmologist right away about a vision change in one or both eyes.7 You are not expected to sort out which is which. That is the visit's job.
How Your Surgeon Works Out What Is Bleeding
You will be dilated and examined. If the blood is thin, your surgeon can see straight through to the retina and often identify the bleeding point at that visit.
If it is dense, the view is blocked, and that is the situation the next test exists for. A blocked view is not a bad sign in itself, it just means the answer needs another instrument.
A B-scan ultrasound is a painless scan done with gel on the closed eyelid. Sound waves map the retina behind the blood and show whether it is lying flat or lifting away.
This is the test that answers the question that matters most on the day: is this only blood, or is the retina detaching underneath it? Expect it to be repeated if the blood does not clear.
Three things, mainly: a retinal detachment under the blood, a rise in eye pressure, and active new vessels still bleeding. Each has a different answer, which is why the examination comes before the plan.
Ask which of the three they are most concerned about in your eye. That answer, more than anything else, shapes what happens next.
What Comes Next: The Treatment Options
If the retina is flat and the pressure is normal, watching is a real choice rather than a delay. Blood can clear on its own, and every procedure carries its own small risks.
Expect head elevation, a pause on heavy lifting, and a review in a few weeks. Ask your surgeon how long they are prepared to wait in your case, and what would shorten that.
An anti-VEGF injection targets the signal that keeps abnormal vessels growing, and completing panretinal laser tackles the same problem from the other direction. The Academy's Preferred Practice Pattern states that anti-VEGF agents reduce the severity of diabetic retinopathy and treat proliferative disease effectively.5
Laser is often held until enough blood clears for the surgeon to see where to place it, which is part of why the sequence can feel slow.
Some surgeons can swap the blood-stained fluid for air in the clinic, through a fine needle, under numbing drops. It sounds alarming and is usually quick.
In a series of 24 eyes with persistent or recurrent bleeding after diabetic vitrectomy, an office fluid-air exchange cleared the blood after one procedure in 19 of the 24 eyes, 5 needed it repeated, 3 eventually needed further surgery, and average vision improved by one month with no complication seen.8
Repeat surgery is the answer when the blood will not clear, when the retina is detaching, or when the eye pressure cannot be controlled. It is the same operation you have already been through, usually shorter.
This is not a punishment for a failed first attempt. For some eyes, the first surgery had to be done in the middle of a bleed, and the second is the one that finishes the job in a clear field.
Risks, Complications and the Realistic Outlook
The honest headline is that most eyes get their vision back, though not always to the level they had before. In the 315-eye series, vision improved after retreatment in 31 of the 32 eyes that had bled and fell in 1.4
The National Eye Institute puts the wider principle plainly: treatment can stop vision from getting worse, but it will not undo damage that has already happened.6
The one that matters most is neovascular glaucoma, where new vessels block the eye's drainage and the pressure climbs. It is uncommon, and it is the reason pain and redness get looked at quickly.
In a multicenter study of 268 eyes operated for proliferative diabetic retinopathy with bleeding, 25 of them, about 9 of every 100, developed neovascular glaucoma within a year, and bleeding after surgery was one of the independent risk factors.9 A hard, painful, red eye is a same-day call.
Some eyes bleed once and are done. Others bleed two or three times over months as the vessels quiet down, and that pattern is disheartening without being a disaster.
The bleeds in the 315-eye series appeared anywhere from 1 to 210 days after surgery, with an average of 51 days.4 Ask your surgeon at what point they would change the plan rather than repeat it.
When to Call Your Surgeon
A curtain or shadow in your vision, sudden flashing lights, severe eye pain, a hard red eye, or vision falling over hours rather than days all deserve a same-day call. The Academy says to call an ophthalmologist immediately about the warning signs of a detached retina.1
If you cannot reach your surgeon's office, an urgent eye service or an emergency department can examine you. Say that you have had a vitrectomy and when.
Call within a few days for a new crop of floaters without pain, a haze that is thickening rather than settling, or vision that had been improving and has stalled. None of these is an emergency, and all of them change the plan.
Call too if you were told to expect clearing by a certain point and that point has passed. A rebooked review is easier than a rescue.
Have the date of your vitrectomy, whether a gas or oil bubble was placed, the drops you are on, and whether you take a blood thinner.
The Academy notes that a patient with a gas bubble in the eye has to hold a particular head position and must not fly or travel to high altitude until the bubble has gone.3 If you are unsure whether your bubble is still there, ask.
Questions People Ask After a Rebleed
No. Bleeding again is a recognized complication of operating on a diabetic eye, not a sign of a botched operation. It happened in about 35 of every 100 eyes in one review of diabetic vitrectomy, and most of those bleeds were mild or moderate.2 The surgery did what it was meant to do, which was clear the old blood and treat the retina. The vessels underneath simply need longer to settle.
There is no single answer, and your surgeon's estimate for your eye beats any figure here. A light bleed can fade over days to weeks; a dense one can take considerably longer or need help. What matters more than the calendar is the trend, so report vision that stops improving or starts sliding rather than waiting out an arbitrary deadline.
Keeping your head elevated, including propped up at night, is commonly advised so that blood settles out of your line of sight, and many surgeons also ask for a pause on heavy lifting and straining. Lying flat on your back all day is not usually the instruction. If you were given specific positioning for a gas bubble, that takes priority, so follow the one your own surgeon gave you.
Not on your own. Stopping aspirin, warfarin or a newer anticoagulant carries its own risks, including stroke and clots, and that trade-off belongs to the doctor who prescribed it. Tell your eye surgeon exactly what you take, including anything bought over the counter, and ask the two of them to settle it between them rather than guessing at home.
Often not. Many rebleeds settle with time, an injection, more laser, or an office procedure. In one series of eyes needing help with persistent bleeding, an office air exchange sorted it in 19 of 24 eyes and only 3 went on to further surgery.8 Repeat vitrectomy is reserved for blood that will not clear, a detaching retina, or pressure that cannot be controlled.
Only if you still meet the legal vision standard where you live, and only if the eye is stable, which your surgeon and the law decide, not this page. A dense one-sided hemorrhage takes away depth judgment and side vision on that side. If you are unsure, do not drive until you have been examined and told it is safe.
More Questions About Causes, Recovery and What Comes After
Because the blood moves. It is suspended in fluid rather than fixed in place, so posture and movement change how much of it sits in your line of sight. This is the reasoning behind the advice to keep your head elevated. A haze that shifts about is not a sign the eye is getting worse, though a haze that keeps thickening is worth a phone call.
Not reliably. The known risk factors in one review were younger age, higher fasting glucose and higher blood pressure at surgery.2 Two of those are things a team can work on before a planned operation, but many diabetic vitrectomies are done urgently, when there is no time to optimize anything. Glucose and blood pressure control still lowers retinopathy risk going forward.5
Repeated bleeding shifts the conversation from waiting to acting. Your surgeon will look for a treatable reason: tissue growing in at the entry sites, new vessels still active on the optic nerve, or laser that has not covered enough retina. Each of those was among the causes found in a published series.4 Ask directly which one they think applies to your eye.
Losing an eye from this is not the usual outcome, and most eyes recover useful vision after retreatment.4 The complication to watch for is neovascular glaucoma, which followed surgery in about 9 of every 100 eyes in one multicenter study.9 It is why pain, redness and a hard eye get seen the same day rather than at the next routine visit.
Write these down before your review, and write the answers next to them.
- Is my retina flat on the ultrasound, and is my eye pressure normal?
- What do you think is bleeding, and can you see it yet?
- How long will you watch before doing something, and what would change that?
- Have I had enough panretinal laser, and is more planned?
- Should I keep taking my blood thinner, and who decides that with my other doctor?
- Which symptoms mean I call you the same day?
- American Academy of Ophthalmology, EyeSmart patient education (2025). Detached Retina.
- Journal of Vitreoretinal Diseases (free full text via PubMed Central) (2025). Risk Factors for Recurrent Vitreous Hemorrhage After 25-Gauge Pars Plana Vitrectomy in Patients With Proliferative Diabetic Retinopathy.
- American Academy of Ophthalmology, EyeSmart patient education (2026). What Is Vitrectomy?.
- Current Eye Research (PubMed record) (2010). Reasons for and management of postvitrectomy vitreous hemorrhage in proliferative diabetic retinopathy.
- American Academy of Ophthalmology (2024). Diabetic Retinopathy Preferred Practice Pattern.
- National Eye Institute, National Institutes of Health (2025). Diabetic Retinopathy.
- American Academy of Ophthalmology, EyeSmart patient education (2025). Diabetic Retinopathy: Causes, Symptoms, Treatment.
- Arquivos Brasileiros de Oftalmologia (free full text via PubMed Central) (2024). Results of office-based fluid-air exchange for postvitrectomy hemorrhage in diabetic retinopathy.
- Scientific Reports (free full text via PubMed Central) (2019). Risk Factors of Neovascular Glaucoma After 25-gauge Vitrectomy for Proliferative Diabetic Retinopathy with Vitreous Hemorrhage: A Retrospective Multicenter Study.