HWN Suggests

Floaters: Retinal Detachment, Posterior Vitreous Detachment, or Vitreous Hemorrhage?

Early vitreous hemorrhage appears as low-amplitude hyperechoic areas, which may require an increase in gain to fully appreciate. As the blood matures it forms mobile membranes, which can be differentiated from retinal detachment by their fine structure, their lack of attachment to the optic disc, and anterior to posterior orientation. When the patient moves the eye, these membranes move like “swaying seaweed”.

Posterior vitreous detachment is seen as a freely mobile hyperechoic membrane that swirls away from the optic disc with movement of the eye. This finding differs from a retinal detachment in that it “crosses the midline,” with the optic disc representing the midline.

read full article

Featured

 Gaining the Diagnosis of Vitreous Hemorrhage with Ultrasound

Vitreous hemorrhage occurs when extravasated blood enters here often due to three main causes: Diabetic retinopathy, vitreous detachment (with or without retinal detachment), or ocular trauma (ie foreign body or shaken baby syndrome). Visual acuity and retention of macular function depend on the extent of hemorrhage; as little as 12.5 microliters of blood can cause vision changes or painless vision loss [3]. Patients will present complaining of unilateral painless vision changes described as a hazy fog.

 Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department

In the study, retinal detachment had the highest sensitivity compared with VH and VD. Among those, RD is the only true ophthalmologic emergency, therefore emergency medicine clinician’s ability to recognize findings more consistent with RD compared to VH and VD may influence the urgency for which patients should be evaluated by ophthalmology.

Articles of Interest

How Do I Work Up and Manage a Patient With a Vitreous Hemorrhage?

Patients with vitreous hemorrhage should be evaluated carefully for the presence of retinal breaks or detachment, neovascularization of the iris or angle, glaucoma, and intraocular tumors. In the absence of these pathologies, most vitreous hemorrhages may be safely observed. When indicated, however, pharmacologic and/or surgical intervention may allow treatment of the underlying cause and may also speed visual improvement for your patient.

Vitreous Hemorrhage: From One Medical Student to Another

Fortunately, three conditions cause 59 to 88.5% of VH cases: proliferative diabetic retinopathy, posterior vitreous detachment (PVD), and ocular trauma. In most circumstances, normal vessels only bleed in the setting of trauma or PVD. The prognosis and management of VH depends on the underlying pathology. VH clears slowly, on the order of 1% per day.

Acute Visual Loss in the Emergency Department: Pearls and Pitfalls

Of note, it is often difficult to differentiate on US vitreous hemorrhage and retinal detachment. However, there are three distinct findings that will help distinguish the two: retinal detachments can be followed posteriorly to the optic disk, vitreous hemorrhages remain horizontal when the patient moves the eye side to side, and vitreous hemorrhages are often seen in the middle section of the posterior eye.

Approach to the patient with flashes and/or floaters

The acute onset of monocular flashes and/or floaters is a common presentation to primary care providers. Most often, this represents a posterior vitreous detachment (PVD), an age-related condition with a prevalence that increases from 24% in adults aged 50 to 59 to 87% among those aged 80 to 89 years. However, the differential diagnosis also includes concerning retinal pathology, such as a retinal tear or detachment.

Eyes for Ears

This week, we review an organized differential diagnosis for vitreous hemorrhage for when you encounter it in the emergency room and clinic.

Flashes and floaters – retinal detachment rule out

Your job: A good depressed exam, ensuring there is no retinal tear / detachment. 90% of these calls will be posterior vitreous detachments, and will require only monitoring. If you are unsure, call in backup. There is one important distinction here: macula on or macula off. If the macula is ON, surgery is generally indicated urgently, as the prognosis is worse if the detachment eventually reaches the macula. If the macula is already OFF, the situation is less emergent, and the standard of care is usually to do surgery within a few days. This is because it is impossible to diagnose and get a patient to the OR within the ~90 minute time frame it takes before there is permanent ischemic damage to the retina. If you find a flap tear without detachment, you will usually call in backup to help laser around the flap tear the same day.

Flashing And Floating

What is the differential diagnosis?, Posterior vitreous detachment, vitreous haemorrhage, retinal break, retinal detachment, retinal hemorrhage.

Ocular Ultrasound: From Floaters to Fogginess

Floaters, often described by patients as lines, circles, dots, cobwebs, and other shapes, are common as part of the degenerative process of the vitreous body. While in the chronic setting they are thought to be related to condensation of the vitreous collagen fibers, new onset floaters in patients 50 years or older have been related to PVD in 95% of cases. Of patients with vitreous floaters and/or flashes as a consequence of PVD, the incidence of RD is 14%. If the PVD is complicated by vitreous hemorrhage, the incidence of RD rises to 70%.

Posterior Vitreous Detachment: peeling paint

The differential diagnosis for a patient presenting with complaint of floaters includes vitreous hemorrhage (which may be secondary to diabetic retinopathy or other vasculopathy or can occur from a PVD), vitritis (usually associated with eye redness, +/- eye pain, presence of anterior segment inflammation, history of systemic autoimmune or infectious disease) or migraine (typically lasts 20 minutes and may or may not be associated with headache).

Vitreous Hemorrhage: Diagnosis and Treatment

The symptoms of vitreous hemorrhage are varied but usually include painless unilateral floaters and/or visual loss. Early or mild hemorrhage may be described as floaters, cobwebs, haze, shadows or a red hue. More significant hemorrhage limits visual acuity and visual fields or can cause scotomas. Patients often say vision is worse in the morning as blood has settled to the back of the eye, covering the macula.

Resources

EyeWiki

Although the diagnosis of vitreous hemorrhage is often straightforward to make on funduscopic examination or ultrasonography, further investigation may be required to determine the underlying etiology.