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

  Abstract 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]

• 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]

  Convergence insufficiency Internuclear ophthalmoplegia One and a half syndrome Refraction Refractive error Hyperopia Myopia Astigmatism Anisometropia / Aniseikonia Presbyopia Vision disorders Blindness Amblyopia Leber's congenital amaurosis Diplopia Scotoma [en.wikipedia.org]

  A peripheral ring scotoma (detectable by visual field testing) widens gradually, and central vision may also be affected in advanced cases. [msdmanuals.com]

  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]

  Retinal lesions have several characteristics, [42, 43] as follows: Initial examination typically reveals 1 or 2 foci of disease. Multifocal disease at time of presentation is uncommon. [emedicine.medscape.com]

• Marcus Gunn Pupil

  Gunn pupil Adie syndrome Miosis Mydriasis Cycloplegia Parinaud's syndrome Other Nystagmus Childhood blindness Infections Trachoma Onchocerciasis This article about an ophthalmic disease is a stub. [en.wikipedia.org]

• 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]

• Fixed Pupils

  SIGNS Poor feeding Vomiting Apnea Decreased tone Decreased level of consciousness Seizures Irritability Fixed pupils Bradycardia Bulging fontanelles Posturing DIAGNOSIS History Physical examination Labs: CBC, coagulation studies, LFT's, and amylase. [webeye.ophth.uiowa.edu]

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]

• HLA-B27

  HLA–B51, HLA-B27, HLA-B5) and enzyme-linked immunosorbent assay (ELISA) or Western-blot-specific testing for: human immuno-deficiency virus (HIV), Lyme disease, toxoplasmosis and tuberculosis. [optometricmanagement.com]

• HLA-B5

  HLA–B51, HLA-B27, HLA-B5) and enzyme-linked immunosorbent assay (ELISA) or Western-blot-specific testing for: human immuno-deficiency virus (HIV), Lyme disease, toxoplasmosis and tuberculosis. [optometricmanagement.com]

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.