Vitreous Hemorrhage: Causes and Treatment
What Is Vitreous Hemorrhage?
Vitreous hemorrhage happens when blood leaks into the vitreous (the clear, gel-like substance that fills the inside of your eye). The vitreous sits between the lens at the front of your eye and the retina at the back. When blood enters this space, it blocks light from reaching the retina and can reduce your vision.
Some people lose vision in minutes. Others notice a slow increase in floaters or a red tint over days. The amount of bleeding determines how much your sight is affected.
Blood in the vitreous can signal a serious problem behind it, such as a torn retina or damaged blood vessels. Without prompt evaluation, these underlying conditions can lead to permanent vision loss. A retinal tear, for example, may progress to a full retinal detachment if left untreated.
You should seek eye care the same day if you notice a sudden shower of new floaters, a red or dark cloud across your vision, or sudden blurry vision in one eye. These symptoms may appear with no pain at all.
People with diabetes face the highest risk. Those with a history of eye trauma, sickle cell disease, or blood vessel problems in the retina also have elevated risk. Age plays a role too, because the vitreous gel shrinks and pulls away from the retina as you get older.
Adults under 40 are more likely to develop vitreous hemorrhage from an injury, while older adults more often develop it from blood vessel disease.
Common Causes of Vitreous Hemorrhage
Proliferative diabetic retinopathy (PDR) is a severe stage of diabetic eye disease where abnormal new blood vessels grow on the surface of the retina. These fragile vessels break and bleed with little provocation. According to the American Academy of Ophthalmology, PDR is the most common cause of vitreous hemorrhage in adults.
High blood sugar damages the small blood vessels in the retina over time. When enough vessels close off, the retina sends chemical signals asking for new blood supply. The new vessels that grow are weak and prone to rupture.
Blunt or penetrating trauma is the leading cause of vitreous hemorrhage in people under 40, as reported by the AAO and EyeWiki. A hit to the eye from a ball, fist, or flying object can rupture blood vessels inside the eye. Penetrating injuries from sharp objects or high-speed debris cause direct damage to internal structures.
Even injuries that seem minor on the outside can cause significant bleeding inside the eye. Anyone who receives a blow to the eye should have a thorough exam to rule out internal damage.
Posterior vitreous detachment (PVD) occurs when the vitreous gel separates from the retina. This is a normal aging change that happens to most people after age 60. During the separation, the gel can tug on a blood vessel and cause it to bleed.
Sometimes the pulling force tears the retina itself. A retinal tear allows fluid to seep behind the retina, which can cause retinal detachment. New floaters with flashes of light are warning signs of PVD or a retinal tear.
A retinal vein occlusion (RVO) is a blockage in one of the veins that carries blood away from the retina. The backed-up pressure causes blood to leak out of the vessel walls. In severe cases, this blood spills into the vitreous cavity.
Risk factors for RVO include high blood pressure, diabetes, glaucoma, and blood clotting disorders. The condition usually affects one eye at a time.
People with sickle cell disease can develop abnormal blood vessels in the retina, similar to those seen in diabetic eye disease. These fragile vessels are prone to bleeding. Sickle cell retinopathy is an under-recognized cause of vitreous hemorrhage, especially in younger patients.
Regular dilated eye exams help catch these changes before bleeding occurs. Early treatment can prevent vision loss.
Symptoms and Diagnosis
The most common symptom is a sudden change in vision. You may experience any of the following:
- A sudden burst of new floaters that look like spots, cobwebs, or dark strings
- A red, brown, or dark shadow spreading across your vision
- Blurred or hazy vision that comes on within hours
- Seeing a reddish tint over everything
- Vision that is worse in the morning and clears somewhat as the day goes on, because blood settles overnight
Your eye doctor will perform a dilated eye exam to look at the vitreous and retina. If the blood is too thick to see through, the doctor will order an ultrasound of the eye. This painless test uses sound waves to create an image of the structures behind the blood.
The ultrasound helps the doctor check for retinal detachment, retinal tears, or masses. Your doctor will also check your eye pressure and examine the front of the eye for other signs of damage.
Doctors grade vitreous hemorrhage based on how well they can see the retina through the blood. A mild hemorrhage allows a clear view of the retina and its blood vessels. A moderate hemorrhage obscures some details but still shows the optic nerve. A severe hemorrhage blocks the view of the retina entirely.
The grade helps guide treatment decisions. Mild cases may clear on their own, while severe cases often need surgery.
Treatment Options
For mild cases, your doctor may recommend a period of observation. Conservative management includes restricting strenuous activity, sleeping with your head elevated at about 30 to 45 degrees, and avoiding blood-thinning medications such as anticoagulants and NSAIDs. Head elevation allows blood to settle to the bottom of the eye, which can partially clear your central vision.
Your doctor will schedule frequent follow-up visits to monitor clearing and watch for complications like retinal detachment. This observation period typically lasts one to three months.
When the retina is visible through the blood, laser panretinal photocoagulation (PRP) is the primary treatment for hemorrhages caused by abnormal blood vessel growth. PRP uses a laser to create small burns across the peripheral retina. These burns reduce the retina's demand for oxygen and cause the abnormal vessels to shrink.
The procedure takes place in the office and may require more than one session. PRP does not restore lost vision, but it can prevent future bleeding episodes.
Anti-VEGF (vascular endothelial growth factor) medications block the chemical signal that drives abnormal blood vessel growth. Your doctor injects these medications directly into the eye. They can serve as a bridge treatment to slow bleeding while you wait for laser treatment or surgery.
These injections can help abnormal vessels shrink quickly. However, their effect is temporary, so most patients still need laser treatment or surgery for a lasting solution.
Pars plana vitrectomy (PPV) is a surgical procedure where the surgeon removes the blood-filled vitreous gel through tiny incisions in the eye. The surgeon replaces the gel with a clear saline solution. During the same operation, the surgeon can apply laser treatment directly to the retina.
PPV is the procedure of choice for hemorrhages that do not clear on their own after one to three months of observation, according to the AAO. A 2024 study in the American Journal of Ophthalmology found that patients who received early PPV within one month had better outcomes. 65% of patients who had early surgery achieved 20/40 vision or better, compared to 45% of those whose surgery was delayed.
Your doctor will recommend surgery sooner if an ultrasound shows a retinal detachment behind the blood. Surgery is also needed when the hemorrhage is too dense to allow laser treatment, or when the bleeding keeps recurring despite other treatments.
Patients with diabetes-related hemorrhage who have not yet received PRP are strong candidates for early vitrectomy with endolaser. Waiting too long can allow scar tissue to form on the retina, making surgery more difficult.
Recovery and Long-Term Outlook
Recovery time depends on the cause and the treatment used. After vitrectomy, most patients use antibiotic and anti-inflammatory eye drops for several weeks. Activity restrictions usually last two to four weeks. Your doctor may ask you to keep your head in a certain position to help healing.
Vision improvement is gradual. Some patients notice better vision within days, while others need weeks or months for full clearing.
The hemorrhage can come back if the underlying cause is not controlled. People with diabetes need to manage blood sugar, blood pressure, and cholesterol to reduce their risk of further bleeding. Regular dilated eye exams allow your doctor to catch new abnormal vessel growth before it causes another hemorrhage.
Patients with retinal vein occlusions or sickle cell retinopathy also need ongoing monitoring. Your doctor will create a follow-up schedule based on your specific condition.
You can lower your risk of future episodes by following these steps:
- Keep diabetes and blood pressure well controlled
- Attend all scheduled eye exams
- Wear protective eyewear during sports and high-risk activities
- Report any new floaters or vision changes to your eye doctor right away
Your Questions About Vitreous Hemorrhage
Yes, mild vitreous hemorrhages sometimes clear without surgery. Your body can absorb small amounts of blood over weeks to months. However, your doctor still needs to examine the eye to make sure there is no retinal tear or detachment hiding behind the blood.
Most vitreous hemorrhages cause no pain at all. You may notice sudden floaters, blurred vision, or a dark shadow, but discomfort is unusual unless the hemorrhage resulted from trauma that also injured other parts of the eye.
Most people return to normal daily activities within two to four weeks after vitrectomy. Full visual recovery can take several months. Your surgeon will give you specific guidelines based on your situation.
The outcome depends on the underlying cause. If the retina is healthy beneath the blood, vision often recovers well after the blood clears. If the retina has been damaged by disease or detachment, some vision loss may be permanent.
Your doctor will likely ask you to avoid strenuous exercise, heavy lifting, and bending at the waist until the hemorrhage stabilizes. These activities can increase blood flow to the eye and worsen the bleeding. Light walking is usually safe, but follow your doctor's specific advice.
Do not stop any medication without talking to the prescribing doctor first. Your eye doctor and primary care doctor will work together to decide whether temporarily stopping blood thinners is safe for you. Stopping these medications carries its own risks.
Take Action to Protect Your Sight
If you notice sudden floaters, a dark shadow, or blurry vision in one eye, contact an eye care professional the same day. Early evaluation and treatment give you the best chance of preserving your vision. Schedule regular dilated eye exams, especially if you have diabetes or other risk factors for vitreous hemorrhage.