Retinal Hemorrhages: Causes, Symptoms, and Treatment
Understanding Retinal Hemorrhages
A retinal hemorrhage is bleeding that occurs in or near the retina. Blood can collect in different layers of the retina or in the spaces around it. The location, size, and pattern of bleeding give a retina specialist important information about what caused it. Retinal hemorrhages can range from tiny dots to large areas of blood that block vision.
These hemorrhages are not a disease by themselves. They are a sign that something is affecting the blood vessels in the eye. Finding the cause is a key part of diagnosis and treatment.
Retinal hemorrhages are classified by where they occur and how they look. Each type provides clues about the underlying cause.
- Flame-shaped hemorrhages spread along the nerve fiber layer near the surface of the retina. They look like small red streaks and are common in conditions that affect arteries, such as high blood pressure.
- Dot and blot hemorrhages occur deeper in the retina. Dot hemorrhages are small and round. Blot hemorrhages are larger and more irregular in shape. Both are frequently seen in diabetic retinopathy.
- Preretinal or subhyaloid hemorrhages collect between the retina and the vitreous gel (the clear gel filling the eye). They can appear as a large pocket of blood and may cause sudden vision changes.
- Vitreous hemorrhages happen when blood leaks into the vitreous gel itself. This type can cause significant vision loss because the blood blocks light from reaching the retina.
The underlying process involves damage to the walls of retinal blood vessels. Conditions like diabetes, high blood pressure, and blood disorders can weaken or change these vessel walls over time. When a weakened vessel breaks or leaks, blood escapes into the surrounding tissue.
In some cases, the eye grows abnormal new blood vessels in response to poor blood flow. These new vessels are fragile and break easily, leading to more severe bleeding. This process is called neovascularization and is especially common in advanced diabetic retinopathy.
Who Is Affected and Risk Factors
Several common health problems raise the risk of retinal hemorrhages. People with diabetes face one of the highest risks. An estimated 9.60 million people in the United States had diabetic retinopathy in 2021, representing about 26.43% of those with diabetes (PMC, 2023). High blood pressure, high cholesterol, and atherosclerosis (hardening of the arteries) also damage retinal blood vessels over time.
Blood disorders, certain infections, and conditions that reduce oxygen delivery to tissues can also cause bleeding in the retina. Age-related macular degeneration is another risk factor, particularly in its advanced forms.
Retinal hemorrhages are more common in adults older than 40. As people age, they are more likely to develop conditions like diabetes and high blood pressure that affect eye health. For people with type 1 diabetes, early onset of the disease and longer duration increase the chance of vitreous hemorrhage. In one study, vitreous hemorrhage developed in 39% of eyes despite prior laser treatment (Medscape).
People who take blood-thinning medications such as aspirin or warfarin have a higher risk of retinal hemorrhages. These medications reduce the blood's ability to clot, making bleeding more likely when vessel damage occurs.
Trauma to the eye or head is another important cause. In newborns, birth trauma is the leading cause of retinal hemorrhages. Around half of babies born through assisted delivery methods, such as vacuum extraction or forceps, have a retinal hemorrhage at birth (Cleveland Clinic). Among eligible neonates in one study, 24.8% had neonatal retinal hemorrhage (MDPI, 2022).
Signs and Symptoms
Retinal hemorrhages do not cause pain. Many people do not notice any symptoms at all, especially when the bleeding is small or located away from the center of vision. When symptoms do occur, the most common one is sudden vision loss or blurring in one eye.
As a hemorrhage progresses, people may notice spots or dark strings floating in their vision, called floaters. Some people see dark or empty areas in their field of view. These changes can develop suddenly or over a period of days.
Certain symptoms require urgent attention. A sudden increase in floaters, flashes of light, a shadow or curtain moving across the vision, or sudden vision loss in one eye are all warning signs that need immediate evaluation. See a retina specialist or go to the emergency room immediately if you experience any of these symptoms. Delaying care can lead to permanent vision loss.
Some retinal hemorrhages are found only during a routine eye exam. A retina specialist or eye care provider may see bleeding inside the eye before you notice any vision changes. This is one reason regular eye exams are important, especially for people with diabetes, high blood pressure, or other risk factors.
Diagnosis and Testing
The first step in diagnosing a retinal hemorrhage is a dilated eye exam. During this exam, drops are placed in the eyes to widen the pupils. This allows the retina specialist to look at the retina and its blood vessels using a specialized microscope. The type, location, and pattern of any bleeding can often be identified during this exam.
Advanced imaging helps a retina specialist see the hemorrhage in greater detail and identify its cause.
- Optical coherence tomography, or OCT, uses light waves to create detailed cross-section images of the retina. It can show exactly which layer of the retina contains the blood.
- Fluorescein angiography involves injecting a special dye into a vein in the arm. As the dye travels through the retinal blood vessels, photographs are taken. This test shows leaking vessels, areas of poor blood flow, and abnormal new blood vessel growth.
- Ultrasound of the eye may be used when a large vitreous hemorrhage blocks the view of the retina. Sound waves create an image of the structures behind the blood.
Because retinal hemorrhages often point to a systemic condition, a retina specialist may recommend blood tests. These can check blood sugar levels, blood cell counts, clotting factors, and other markers. Identifying and treating the underlying cause is essential for preventing future hemorrhages.
Treatment Options
Small retinal hemorrhages that do not affect vision may not require immediate treatment. The body can often reabsorb small amounts of blood over weeks to months. A retina specialist will schedule follow-up visits to monitor healing and watch for complications. Flame-shaped hemorrhages, for example, typically clear within about 6 to 12 weeks.
Controlling the condition that caused the hemorrhage is one of the most important parts of treatment. For people with diabetes, tighter blood sugar management can slow or stop further damage to retinal blood vessels. Lowering blood pressure and cholesterol levels also help protect the retina. If a blood disorder is the cause, appropriate medical treatment of that condition is needed.
Anti-VEGF medications block vascular endothelial growth factor, a protein that promotes the growth of abnormal, fragile blood vessels. These drugs are injected directly into the eye in a procedure called an intravitreal injection. They are used to reduce bleeding and swelling, particularly in cases related to diabetic retinopathy and retinal vein occlusions.
Common anti-VEGF medications include Eylea (aflibercept), typically given every 4 to 8 weeks after an initial loading phase, and Lucentis (ranibizumab), given approximately every 4 weeks. Avastin (bevacizumab) is also widely used for retinal hemorrhages, though it is important to note that Avastin is FDA-approved for cancer treatment and is used off-label for eye conditions. Vabysmo (faricimab) is a newer option that can be given every 4 to 16 weeks after loading doses. Proliferative diabetic retinopathy is the most frequent cause of vitreous hemorrhage in adults, accounting for 31.5% to 54% of cases in the United States (Medscape).
Laser photocoagulation (a treatment that uses a focused beam of light to seal leaking or damaged blood vessels) is often used when abnormal new vessels are growing on the retina. Panretinal photocoagulation, or PRP, applies laser to a wide area of the peripheral retina. This reduces the signals that drive new vessel growth and helps lower the risk of severe bleeding.
Laser treatment may be used alone or together with anti-VEGF injections, depending on the severity of the condition.
In certain types of retinal hemorrhages, particularly hemorrhagic occlusive retinal vasculitis (HORV), a rare condition linked to the use of intraocular vancomycin during cataract surgery, corticosteroids play an important role. Treatment for HORV involves aggressive systemic and topical corticosteroids. Periocular or intraocular steroid injections may also be used. Early anti-VEGF treatment and early panretinal photocoagulation are recommended in these cases.
The FDA added a warning in 2017 to vancomycin injection labeling, noting that HORV, including permanent vision loss, has occurred in patients receiving vancomycin inside the eye during or after cataract surgery (FDA, 2017). A joint task force by the American Society of Cataract and Refractive Surgery and the American Society of Retina Specialists identified 23 patients (36 eyes) affected by this condition (ASCRS/ASRS).
When a vitreous hemorrhage is severe or does not clear on its own, a retina specialist may recommend a vitrectomy. This is a surgery to remove the vitreous gel, along with the blood, from inside the eye. The gel is replaced with a clear saline solution or a gas bubble. Vitrectomy can restore vision and also allows the surgeon to treat any underlying problems found during the procedure, such as retinal tears or detachment.
What to Expect
Recovery depends on the type and severity of the hemorrhage, as well as the underlying cause. Small hemorrhages may resolve on their own within weeks. Larger hemorrhages, especially vitreous hemorrhages, can take months to clear without surgery. After vitrectomy, recovery typically takes several weeks, and vision may gradually improve over that time.
Regular follow-up appointments with a retina specialist are essential. These visits allow the specialist to monitor healing, check for new bleeding, and adjust treatment as needed. People with chronic conditions like diabetes will need ongoing eye exams, often several times per year, to catch any changes early.
Vision outcomes vary widely depending on the cause and extent of bleeding. Small hemorrhages that do not involve the central retina often have good outcomes. Hemorrhages affecting the macula (the center of the retina responsible for sharp vision) may cause lasting changes in vision. Early detection and treatment generally lead to better results.
Living With Retinal Hemorrhages
For many people, preventing future retinal hemorrhages means managing the health conditions that cause them. Keeping blood sugar levels within target ranges, taking blood pressure medications as prescribed, and following a heart-healthy diet can all reduce the risk of further bleeding. Working closely with both a primary care provider and a retina specialist is important for long-term eye health.
While recovering from a retinal hemorrhage, some people need to adjust their daily activities. A retina specialist may advise avoiding heavy lifting or strenuous exercise during the healing period. If vision is significantly affected, practical steps like using magnifying devices, improving home lighting, and arranging transportation can help maintain independence.
Vision changes can cause stress and worry. It is normal to feel anxious about the possibility of further bleeding or vision loss. Support from family, friends, or a counselor can be helpful. Many communities also offer low-vision support groups and resources.
When to See a Retina Specialist
People with diabetes should have a comprehensive dilated eye exam at least once a year. Those with high blood pressure, blood disorders, or a history of retinal hemorrhages may also need regular screening. Early detection of retinal changes often allows treatment to begin before significant vision loss occurs.
Seek immediate care from a retina specialist or go to the emergency room if you experience a sudden increase in floaters, flashes of light, a dark curtain or shadow over part of your vision, or sudden loss of vision in one eye. These symptoms can indicate a serious problem that requires prompt treatment to protect your sight.
If you have been diagnosed with a retinal hemorrhage, follow all recommendations from your retina specialist regarding follow-up visits and treatment. Report any new or worsening vision changes right away. Ongoing communication with your specialist helps ensure the best possible outcomes.
Questions and Answers
Small retinal hemorrhages can sometimes resolve on their own as the body reabsorbs the blood. Flame-shaped hemorrhages in the superficial retina, for instance, often clear within about 6 to 12 weeks. However, the cause of the hemorrhage still needs to be identified and managed. Larger hemorrhages, especially those involving the vitreous, may require anti-VEGF injections, laser treatment, or surgery. A retina specialist can determine whether observation is safe or whether active treatment is needed.
Maintaining blood sugar levels as close to target as possible is the most effective way to reduce the risk of diabetic retinopathy and related hemorrhages. Controlling blood pressure and cholesterol levels also helps protect retinal blood vessels. Annual dilated eye exams allow a retina specialist to catch early changes before serious bleeding occurs. Following all prescribed medications and maintaining regular visits with both a primary care provider and a retina specialist are key steps.
Retinal hemorrhages are relatively common in newborns, particularly after assisted deliveries using vacuum extraction or forceps. In most cases, neonatal retinal hemorrhages resolve on their own within the first few weeks of life and do not cause lasting vision problems. However, hemorrhages that are large or involve the fovea (the very center of the macula) may require monitoring by a pediatric retina specialist to ensure proper healing.
A retinal hemorrhage refers to bleeding within or directly on the surface of the retina. A vitreous hemorrhage is bleeding into the vitreous gel, the clear substance that fills the interior of the eye. Vitreous hemorrhage often causes more noticeable symptoms, such as a sudden cloud of floaters or significant vision loss, because the blood blocks light from reaching the retina. Both types require evaluation by a retina specialist to determine the cause and appropriate treatment.
Vision recovery depends on several factors, including the size and location of the hemorrhage, the underlying cause, and how quickly treatment begins. Many people experience significant improvement, especially when the hemorrhage is small or does not affect the macula. In more severe cases, some degree of vision change may persist even after treatment. A retina specialist can provide a more specific outlook based on your individual situation and examination findings.