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Retinal Hemorrhage

Retinal hemorrhage refers to bleeding within the light-sensitive tissue on the posterior wall of the eye. A retinal hemorrhage may be caused by diseases (e.g., hypertension, retinal vein occlusion, diabetes), use of certain medications (e.g., anticoagulant therapy), or a head injury.


Presentation

The presentation and appearance of a hemorrhage vary based on its location relative to the retina. Retinal hemorrhages are classified as subretinal, intraretinal (superficial and deep), pre-retinal, and vitreous.

  • Subretinal hemorrhages refer to bleeding that is located between the neurosensory retina and retinal pigment epithelium (RPE). The source of bleeding is either the retinal or choroidal circulation [1]. Subretinal hemorrhages appear as extensive dark-red regions, with the retinal vessels clearly visible above.
  • Superficial intraretinal hemorrhages are a result of bleeding from the capillary bed located between the nerve fiber (NFL) and ganglion cell layers [1]. They have a characteristic "flame shape" which is a result of the axons of the ganglion cells squeezing the blood horizontally within itself [1] [2].
  • Deep intraretinal hemorrhages, also called "dot" and "blot", originate from the deep capillary layer and involve either the inner or outer nuclear layers [1] [2]. Dot and blot hemorrhages are easily visualized at the peripheral retina where the nerve fiber layer is thin [3]. They appear small and round because they occur in the deep longitudinally-oriented cell layers within the retina.
  • Pre-retinal hemorrhages are located on the surface of the retina, posterior to the internal limiting membrane and anterior to the NFL. As these hemorrhages resolve, the blood cells settle inferiorly due to gravity resulting in a "boat-shaped" or "crescent" appearance [3].
  • Vitreous hemorrhages occur when blood from a pre-retinal or retinal hemorrhage escapes into the vitreous cavity [4] [5]. Patients with vitreous hemorrhages often report seeing "floaters", cloudy vision, "haze", and/or decreased light perception.
Persistent Cough
  • No retinal hemorrhages were detected in any of 100 consecutive children aged 3 months to 2 years with severe, persistent coughing (0 of 100, 95% CI: 0%- 3%).[ncbi.nlm.nih.gov]
Splinter Hemorrhage
  • Sixteen children had RH: 8 had superficial intraretinal peripapillary RH adjacent to a swollen optic disc, and 8 had only splinter hemorrhages directly on a swollen disc. All had significantly elevated OP (mean: 42 cm H2O).[ncbi.nlm.nih.gov]
Hypertensive Retinopathy
  • For hypertensive retinopathy, most vision problems go away when high blood pressure is treated and lowered.[medical-dictionary.thefreedictionary.com]
  • Hypertensive retinopathy Leukemia Multiple myeloma Trauma Figure 3: A sub-retinal hemorrhage seen in a wet age-related macular degeneration patient.[optometricmanagement.com]
  • Diabetic retinopathy tends to cause multiple pinpoint dot hemorrhages, whereas hypertensive retinopathy tends to be associated with larger flame shaped hemorrhages.[eyedolatryblog.com]
  • Flame-shape hemorrhages “Feathered” or linear retina heme Location: within nerve fiber layer (resolve around six weeks) Possible etiologies: Hypertensive retinopathy Retinal vein occlusions Papilledema Normal-tension glaucoma Anterior ischemic optic neuropathy[optometrystudents.com]
Scotoma
  • A 50-year-old man presented with blurry vision and scotomas in his right eye immediately after a 2-week hiking trip in the Andes at an altitude of 19,600 ft (6000 m).[nejm.org]
  • Neither metamorphopsia nor central scotomas were recorded in Amsler grid tests. The only visual disturbances reported were floaters by one participant in whom retinal bleeding was so extensive that vitreous hemorrhage occurred.[journals.plos.org]
  • 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.[aao.org]
Retinal Lesion
  • This case exemplifies the need for careful monitoring of renal function and retinal lesions not only in patients receiving IFN but also in those following the discontinuation of IFN treatment.[ncbi.nlm.nih.gov]
  • Retinal lesions as clues to disseminated bacterial and candidal infections: frequency, natural history, and etiology. Medicine (Baltimore). 2003;82(3):187-202. None of the authors have any proprietary interest in any aspect of this manuscript.[consultant360.com]
  • Clinical and microscopical features of retinal lesions. In: The retinal circulation . New York: Harper & Row, 1971:167–78. Goetting MG , Sowa B. Retinal haemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation.[adc.bmj.com]
Altered Mental Status
  • Children presenting with lethargy or altered mental status (P 0.0001), subdural hemorrhage (P 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P 0.01546) were likely to have RH[ncbi.nlm.nih.gov]

Workup

Workup begins with a thorough review of the patient's medical history, current medication use, and history of present illness [6]. Any head injuries or trauma should be noted, particularly in young children and infants presenting with a retinal hemorrhage [7] [8]. Since the eyes are located near vital structures in the head and neck region, life-threatening injuries involving the intracranial region, the airway, and the cervical spine need to be considered prior to ocular assessment. In cases where head trauma is suspected or reported, a head computed tomography scan (CT) should be performed immediately [9] [10].

An ophthalmologic exam, using either an ophthalmoscope or fundus camera, is often sufficient to diagnose a retinal hemorrhage. An intravenous injection of a fluorescent dye prior to the ophthalmologic exam allows better visualization of the retinal blood vessels.

Laboratory studies may be done in patients with suspected comorbidities. For example, coagulation studies may be performed in patients with a coexisting intracerebral and retinal hemorrhage to rule out a bleeding disorder and blood cultures performed in patients suspected of having sepsis [10].

Imaging modalities such as a head and neck CT or magnetic resonance imaging (MRI) with contrast and/or angiography may be used to rule out an arteriovenous malformation, cavernous hemangioma, aneurysm, or fibromuscular dysplasia. A head CT should be done in any patient with a recent history of head trauma [10].

Plasmodium Falciparum
  • Retinal hemorrhage is a frequently observed sign in Plasmodium falciparum infection. In Plasmodium vivax infection, however, retinal hemorrhage is very rare; only five cases have been reported in the literature.[ncbi.nlm.nih.gov]
  • Retinal hemorrhages were significantly associated with several indices of severity of Plasmodium falciparum infection: high parasitemia with schizontemia, anemia, elevated serum creatinine and reduced plasma antithrombin III.[ncbi.nlm.nih.gov]

Treatment

  • The hemorrhage was not related to the type of the CNV lesion before treatment.[ncbi.nlm.nih.gov]
  • No eyes needed additional injection or laser treatment. No major systemic or ocular complications were observed.[ncbi.nlm.nih.gov]
  • This case exemplifies the need for careful monitoring of renal function and retinal lesions not only in patients receiving IFN but also in those following the discontinuation of IFN treatment.[ncbi.nlm.nih.gov]
  • Hemorrhage resolved without treatment, and visual acuity returned to 20/25 by the 6-month follow-up visit.[ncbi.nlm.nih.gov]
  • It may be useful as an anti-VEGF treatment in DR, especially in reducing the retinal hemorrhage that often occurs shortly after the switch from oral hypoglycemics to parenteral insulin.[ncbi.nlm.nih.gov]

Prognosis

  • This prognosis is due to several factors, including mechanical damage to the photoreceptors by fibrin infiltration.[retinalphysician.com]
  • Prognosis For retinal hemorrhages associated with retinopathy of prematurity, nearly 85 percent of cases heal without treatment. Diabetic retinopathy is the leading cause of blindness for those between 20 and 65 years old in the U.S.[medical-dictionary.thefreedictionary.com]
  • Discussion CVST is a neurological treatable disease that has good prognosis if diagnosed early.[journal.opted.org]
  • Thus, they often carry an unfavorable prognosis.[optometricmanagement.com]
  • Rupture of the eyeball is considered a severe complication; therefore, patients who suffer rupture often have a poor visual prognosis.[karger.com]

Etiology

  • The etiologies of retinal hemorrhage as well as the literature presently available to support or refute the various diagnoses are discussed.[ncbi.nlm.nih.gov]
  • We review the literature regarding types of retinal hemorrhage and their associated etiologies.[ncbi.nlm.nih.gov]
  • In children with CSVT, if RHs are multilayered, extend beyond the peripapillary region into the rest of the posterior pole or retinal periphery, or occur in the absence of optic disk swelling, another etiology for the RH should be sought.[ncbi.nlm.nih.gov]
  • The most frequent etiology was idiopathic intracranial hypertension (70%). Seventy-four children had papilledema.[ncbi.nlm.nih.gov]
  • The more frequently encountered ocular etiologies associated with dot-and-blot hemorrhages are diabetic retinopathy, idiopathic juxtafoveal retinal telangiectasis, vein occlusion and OIS.[optometricmanagement.com]

Epidemiology

  • She has several years of experience in genetics research, survey design, analysis and epidemiology, working on both infectious and chronic diseases. Lietz holds a Master of Public Health in epidemiology from The Ohio State University.[livestrong.com]
  • Methods Statistics Trigonometry Medical & Nursing Anatomy Anesthesiology Audiology Bacteriology Biochemistry Bioethics Biomedical Science Cardiology Cardiovascular Childbirth Chiropractic Dentistry Dermatology Diagnostic Imaging Drugs Endocrinology Epidemiology[brainscape.com]
  • Diagnosis : Non-accidental trauma (commonly known as Shaken Baby Syndrome) EPIDEMIOLOGY Affects 1200-1400 infants every year. 30% mortality rate. Up to 50% of survivors left with visual impairment. Usually occurs in infants under 6 months of age.[webeye.ophth.uiowa.edu]
  • Pearlman JA, Au Eong KG, Kuhn F, Pieramici DJ: Airbags and eye injuries: epidemiology, spectrum of injury, and analysis of risk factors. Surv Ophthalmol 2001;46: 234–242. Kuhn F, Morris R, Witherspoon CD: Eye injury and the air bag.[karger.com]
Sex distribution
Age distribution

Pathophysiology

  • […] recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology[ncbi.nlm.nih.gov]
  • In this prospective high altitude study, we aimed to gain new insights into the pathophysiology of HAR and explored whether HAR could be a valid early indicator of altitude illness.[journals.plos.org]
  • Understanding the pathophysiology of the retinal vascular system helps in the diagnosis of this and many other ocular diseases, leading to appropriate management.[optometricmanagement.com]
  • What is the pathophysiology of CVST? f. What is the pathophysiology of the headache associated with CVST? g. What indicates poor prognosis in CVST cases? 2. Differential diagnosis: a.[journal.opted.org]

Prevention

  • An optimal balance between acclimatization and subsequent altitude stress appeared to prevent retinal hemorrhage.[ncbi.nlm.nih.gov]
  • Prevention The first step in sound prevention is for people with vision problems, including visual spots, flashes or floaters in the vision, and loss or distortion of visual accuracy, to see an opthalmologist as soon as possible.[medical-dictionary.thefreedictionary.com]
  • During the 2 weeks, he was taking acetazolamide in an effort to prevent altitude sickness and reported having no symptoms during his hike. On examination, his visual acuity was 20/50 in the right eye and 20/20 in the left eye.[nejm.org]
  • Seite 234 - Centers for Disease Control and Prevention: 1994 Revised Classification System for Human Immunodeficiency Virus Infection in Children Less Than 13 Years of Age, MMWR, 43, 1-19, No. ‎[books.google.com]
  • […] within one-tenth of a second to reduce the severity of the bodily harm and to prevent passengers from being ejected from the seats, thus also preventing secondary injuries.[karger.com]

References

Article

  1. Aryan HE, Ghosheh FR, Jandial R, Levy ML. Retinal hemorrhage and pediatric brain injury: Etiology and review of the literature. J Clin Neurosci. 2005;12:624-31.
  2. Levin AV. Retinal hemorrhage in abusive head trauma. Pediatrics. 2010;126:961-70.
  3. Retina. In: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th ed, Ehlers JP, Shah CP (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.274.
  4. Vitreous hemorrhage. In: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th ed, Ehlers JP, Shah CP (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.296.
  5. Al Wadeai EA, Osman AA, Mackey TA, Soliman MM. Epidemiological features of pediatric ocular trauma in egypt. J Opthalmol. 2016; Epub 2016 Oct 5.
  6. Lima VC, Cavalieri GC, Lima MC, Nazario NO, Lima GC. Risk factors for diabetic retinopathy: a case-control study. Int J Retina Vitreous. 2016; 2:21.
  7. Billmire ME, Myers PA. Serious head injury in infants: accident or abuse? Pediatrics. 1985;75:340–2.
  8. Gilliland MG, Luckenbach MW, Chenier TC. Systemic and ocular findings in 169 prospectively studied child deaths: retinal hemorrhages usually mean child abuse. Forensic Sci Int. 1994; 68:117.
  9. Karibe H, Kameyama M, Hayashi T, Narisawa A, Tominaga T. Acute Subdural Hematoma in Infants with Abusive Head Trauma: A Literature Review. Neurol Med Chir (Tokyo). 2016;56:264-73.
  10. Trauma. In: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th ed, Ehlers JP, Shah CP (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.12.

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Last updated: 2018-06-22 05:22