Intraocular hemorrhage (sometimes called hemophthalmos or hemophthalmia) is bleeding inside the eye (oculus in Latin). Bleeding can occur from any structure of the eye where there is vasculature or blood flow, including the anterior chamber, vitreous cavity, retina, choroid, suprachoroidal space, or optic disc. Intraocular hemorrhage may be caused by physical trauma (direct injury to the eye); ocular surgery (such as to repair cataracts); or other diseases, injuries, or disorders (such as diabetes, hypertension, or shaken baby syndrome). Severe bleeding may cause high pressure inside the eye, leading to blindness.
Types Intraocular hemorrhage is classified based on the location of the bleeding:
Hyphema (in the anterior chamber) Suprachoroidal hemorrhage (SCH) is a rare complication of intraocular surgery in which blood from the ciliary arteries enters the space between the choroid and the sclera. It is potentially vision-threatening. In the posterior segment of the eyeball: Vitreous hemorrhage (into the vitreous) Subretinal hemorrhage (under the retina) Submacular hemorrhage (under the macula) Another type of ocular hemorrhage is subconjunctival bleeding, which occurs just underneath the conjunctiva.
Causes A subconjunctival hemorrhage can often occur without any obvious cause or harm to the eye. A strong enough sneeze or cough can cause a blood vessel in the eye to burst. Hyphema is a result of blunt or penetrating trauma to the orbit that increases intraocular pressure, causing tears in the vessels of the ciliary body and iris. Certain medical conditions—such as leukemia, hemophilia, Von Willebrand disease, and sickle cell disease—put patients at risk of developing hyphema, as does the use of anticoagulant medications. Neovascularization of the eye, often associated with diabetes mellitus, is also a risk factor. People who have undergone surgery (such as for cataracts) may develop hyphema during or up to a week after the surgery. Vitreous hemorrhage can be caused by proliferative diabetic retinopathy, vitreous detachment with or without retinal breaks, and trauma. Less common causes include vascular occlusive disease Archived 2022-12-13 at the Wayback Machine, retinal arterial macroaneurysm, hemoglobinopathy, age-related macular degeneration, and intraocular tumors. Subretinal hemorrhage is caused by retinal and/or choroidal circulation. Significant subretinal hemorrhage occurs in several conditions, but is most commonly associated with age-related macular degeneration, presumed ocular histoplasmosis, high myopia, retinal arterial macroaneurysm, and trauma. Other causes include Terson syndrome (as a result of subarachnoid hemorrhage), hemophilia, anticoagulants, and thrombolysis.
Pathophysiology Hemorrhages present differently depending on their type. A subconjunctival hemorrhage appears as a bright red patch on the white (sclera) of the eye and is commonly referred to as a burst blood vessel. In hyphema, blood pools in the anterior chamber, where the iris (the colored part of the eye) and the pupil are located. Hyphemas are graded based on the amount of blood covering the cornea. Once an open globe has been ruled out, intraocular pressure should be checked and treated if greater than 21 mm Hg. All patients with hyphema require ophthalmology consultation. Any patient with a hyphema larger than grade II, elevated intraocular pressure, or sickle cell disease—or who is unable to comply with daily ophthalmology evaluations—should be admitted to the hospital. A vitreous hemorrhage is bleeding into the vitreous gel: the thick, clear fluid in the center of the eye that allows light to pass through to the retina, the nerve fiber layer that sends images to the brain. A subretinal hemorrhage is an accumulation of blood between the photoreceptor layer and the retinal pigment epithelium (RPE), arising from the choroidal or retinal circulation. These hemorrhages are a deep red color and broad in shape, with diffuse margins. They are commonly seen in age-related macular degeneration, presumed ocular histoplasmosis, high myopia, polypoidal choroidal vasculopathy (PCV), retinal macroaneurysm, and trauma. Submacular hemorrhages are commonly seen in choroidal neovascular membranes secondary to age-related macular degeneration. They are an uncommon complication of choroidal or retinal vascular abnormalities, including PCV, choroidal neovascularization (CNV), and retinal macroaneurysm.
Diagnosis A subconjunctival hemorrhage is diagnosed by visual examination; it will present as a red splotch visible to the naked eye. No other testing is required. Hyphema is diagnosed with a slit lamp examination. If the hyphema is large enough, it will also be visible on a penlight exam. Symptoms include bleeding in the front of the eye, sensitivity to light, pain in the eye, and blurry, clouded, or blocked vision. Vitreous hemorrhage may be diagnosed when symptoms such as floaters, haziness, perception of shadows, or cobwebs are present. It is usually painless. Visual acuity may be affected variably depending on the amount of blood in the visual axis. Diagnosis is made with slit lamp examination and confirmed with optical coherence tomography (OCT). Subretinal hemorrhages are diagnosed with a slit lamp examination of the anterior segment, dilated fundus examination, and intraocular pressure measurement. OCT, fundus fluorescein angiography (FFA), and fundus photography are helpful to determine the location and depth of the hemorrhage. One should suspect abusive head trauma if a child younger than three shows retinal hemorrhages with an intracranial injury. Submacular hemorrhage patients often present with decreased central vision, sometimes 20/200 or worse. On a dilated fundus examination, submacular hemorrhage can be observed as an elevation of the retina, which can also be associated with a hemorrhagic detachment of the retinal pigment epithelium.
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