TREATMENT OF DIABETIC VITREOUS HEMORRHAGE

Patients who have diabetes sometimes develop fragile blood vessels in the eye that bleed into the vitreous cavity of the eye causing sudden severe vision loss: vitreous hemorrhage.

pdr_vh

A diabetic vitreous hemorrhage refers to bleeding into the vitreous humor, which is the gel-like substance that fills the center of the eye. This condition is specifically associated with diabetes, a chronic metabolic disorder characterized by elevated levels of blood glucose (sugar).

In individuals with diabetes, the blood vessels throughout the body, including those in the eyes, may be affected by the long-term effects of high blood sugar levels. Diabetic retinopathy is a common complication of diabetes that involves damage to the blood vessels in the retina, the light-sensitive tissue at the back of the eye.

When the blood vessels in the retina are weakened or damaged, they may leak blood into the vitreous humor, leading to a vitreous hemorrhage. The severity of the hemorrhage can vary, and it may cause symptoms such as floaters (dark spots or lines that float in the field of vision), blurred vision, or even complete vision loss, depending on the extent of the bleeding.

Management of diabetic vitreous hemorrhage often involves addressing the underlying diabetic retinopathy and may include interventions such as laser therapy or surgery to stop the bleeding and preserve or restore vision. Regular eye examinations for individuals with diabetes are crucial for early detection and management of diabetic retinopathy and its complications. If you suspect you have any issues with your eyes, it’s important to consult with an eye care professional for a comprehensive eye examination and appropriate management.

dm_vh2

The treatment for diabetic vitreous hemorrhage depends on the severity of the condition, the underlying diabetic retinopathy, and the specific circumstances of the individual patient. Here’s an overview of the potential treatments, including observation, injection therapy, laser treatment, and vitrectomy surgery:

  1. Observation:
    • Appropriateness: Observation may be appropriate in cases where the vitreous hemorrhage is mild, and the bleeding may resolve on its own over time. If the hemorrhage is not causing significant vision loss and the patient’s overall eye health is stable, the doctor may choose to monitor the situation without immediate intervention.
    • Risks and Benefits: The benefit of observation is that it avoids unnecessary interventions. However, the risk is that if the bleeding persists or worsens, it could lead to more severe vision problems over time.
  2. Injection Therapy:
    • Appropriateness: Intravitreal injections of medications, such as anti-VEGF (vascular endothelial growth factor) agents, may be considered to address abnormal blood vessel growth and reduce the risk of further bleeding. This approach is more common when there is evidence of neovascularization (abnormal blood vessel growth) in diabetic retinopathy.
    • Risks and Benefits: The benefit is that anti-VEGF injections can help stabilize or improve vision by reducing abnormal blood vessel growth. Risks may include infection, increased intraocular pressure, and less commonly, retinal detachment.
  3. Laser Treatment:
    • Appropriateness: Laser therapy, such as panretinal photocoagulation (PRP), is often used to treat proliferative diabetic retinopathy and reduce the risk of further bleeding. It may not directly address the existing vitreous hemorrhage but aims to prevent future episodes.
    • Risks and Benefits: Laser treatment can help prevent the progression of diabetic retinopathy and reduce the risk of complications, but it may not fully restore lost vision. Risks include potential damage to the surrounding healthy tissue and a temporary increase in vision blurriness after the procedure.
  4. Vitrectomy Surgery:
    • Appropriateness: Vitrectomy is a surgical procedure that involves removing the vitreous gel and blood from the eye. It is considered when the vitreous hemorrhage is severe, persistent, and significantly affecting vision.
    • Risks and Benefits: The benefit of vitrectomy is the potential for a rapid improvement in vision by removing the blood obstructing the visual pathway. Risks include infection, retinal detachment, and the development of cataracts. Vitrectomy is typically considered when other treatments have not been successful or are not appropriate.

It’s crucial to note that the choice of treatment depends on various factors, and decisions should be made in consultation with an ophthalmologist or retinal specialist who can assess the specific characteristics of the vitreous hemorrhage, the severity of diabetic retinopathy, and the overall health of the patient’s eyes. Regular eye examinations for individuals with diabetes are essential for early detection and timely management of diabetic retinopathy and its complications.

Intravitreal injection of medication, particularly anti-VEGF (vascular endothelial growth factor) agents, is a treatment option for diabetic vitreous hemorrhage, especially when there is significant bleeding that makes it challenging to visualize the retina for other treatments like laser therapy. Here’s a more detailed look at this treatment approach:

Intravitreal Injection:

  1. Purpose:
    • Addressing Neovascularization: Intravitreal injections are often used to target abnormal blood vessel growth (neovascularization) in diabetic retinopathy. Neovascularization can lead to weak and leaky blood vessels, contributing to vitreous hemorrhage.
  2. Medications:
    • Anti-VEGF Agents: Medications such as ranibizumab, bevacizumab, and aflibercept are anti-VEGF agents. VEGF is a protein that promotes the growth of new blood vessels. Anti-VEGF medications work by inhibiting the action of VEGF, reducing the abnormal blood vessel growth and decreasing the likelihood of bleeding.
  3. Procedure:
    • Administration: The medication is injected directly into the vitreous cavity of the eye. The procedure is typically performed in an outpatient setting and is relatively quick.
  4. Frequency:
    • Follow-Up Injections: In many cases, multiple injections are required over a period of time to achieve and maintain the desired therapeutic effect. The frequency of injections depends on the individual patient’s response and the severity of diabetic retinopathy.
  5. Advantages:
    • Immediate Action: Intravitreal injections can provide a relatively rapid response, stabilizing or improving vision by reducing abnormal blood vessel growth.
    • Feasibility in Severe Hemorrhage: Because the injection is delivered directly into the vitreous cavity, it can be performed even when there is too much blood in the eye to visualize the retina clearly. This is an advantage when the hemorrhage is severe, making it difficult to perform laser therapy or other treatments that require a clear view of the retina.
  6. Considerations:
    • Combination Therapy: Intravitreal injections may be used in combination with other treatments, such as laser therapy or vitrectomy, depending on the specific circumstances and the response to initial injections.

It’s important to note that while intravitreal injections can be effective in managing diabetic vitreous hemorrhage, the decision to pursue this treatment, as well as the frequency of injections, is individualized and based on the assessment of the ophthalmologist or retinal specialist. Regular follow-up appointments are crucial to monitor the response to treatment and adjust the management plan as needed. Additionally, potential risks and benefits should be discussed thoroughly between the patient and the eye care professional.

laser_prp

Laser treatment for diabetic vitreous hemorrhage is a therapeutic approach aimed at managing the underlying diabetic retinopathy and preventing further complications, including recurrent bleeding into the vitreous humor. This laser therapy is commonly known as panretinal photocoagulation (PRP).

Panretinal Photocoagulation (PRP):

  1. Purpose:
    • Targeting Abnormal Blood Vessels: PRP is used to treat proliferative diabetic retinopathy, a stage where there is an abnormal proliferation of new blood vessels (neovascularization). These new vessels are fragile and prone to bleeding, contributing to vitreous hemorrhage.
  2. Procedure:
    • Laser Application: During panretinal photocoagulation, a laser is used to create small, scattered burns (photocoagulation) on the peripheral retina. This process reduces the oxygen demand of the retina and decreases the stimulus for abnormal blood vessel growth.
    • Wide Coverage: The laser is applied to the peripheral areas of the retina rather than the central vision, preserving central vision while treating the peripheral retina where neovascularization is occurring.
  3. Goals:
    • Inducing Regression: The laser treatment aims to induce regression of abnormal blood vessels, preventing them from causing further complications such as vitreous hemorrhage.
    • Reducing Risk of Bleeding: By reducing neovascularization, PRP helps lower the risk of bleeding and subsequent vitreous hemorrhage.
  4. Timing:
    • Preventive and Therapeutic: PRP may be used preventively in cases of advanced non-proliferative diabetic retinopathy or early proliferative diabetic retinopathy to reduce the risk of progression to vitreous hemorrhage. It can also be used therapeutically after a vitreous hemorrhage to prevent further episodes.
  5. Number of Sessions:
    • Multiple Sessions: PRP is often performed over multiple sessions to ensure effective coverage of the peripheral retina. The number of sessions may vary based on the severity of diabetic retinopathy and the response to treatment.
  6. Considerations:
    • Visual Effects: PRP treatment can cause some visual side effects, such as peripheral vision loss or decreased night vision, but the benefits in preventing severe vision-threatening complications often outweigh these side effects.
    • Adjunctive Therapy: In some cases, laser treatment may be combined with other therapies, such as intravitreal injections or vitrectomy, depending on the individual patient’s condition.

It’s essential for individuals with diabetes to undergo regular eye examinations to monitor for the development of diabetic retinopathy, and if diagnosed, to discuss appropriate treatment options with their eye care professional. The choice of treatment, including laser therapy, will depend on the specific characteristics of the retinopathy and the overall eye health of the patient.

vit_graphic2
  1. When to Consider Vitrectomy:
    • Severe Hemorrhage: Vitrectomy is typically considered when there is a significant and persistent vitreous hemorrhage that is not clearing on its own and is causing substantial vision impairment.
    • Recurrent Hemorrhage: Vitrectomy is typically considered when there has been a history of recurrent episodes of vision loss from bleeding in the eye.
    • Failure of Other Treatments: If other treatments such as intravitreal injections or laser therapy have not been successful in resolving the hemorrhage.
  2. Timing for Surgery:
    • Individualized Decision: The timing for vitrectomy surgery is often individualized and depends on factors such as the severity of the hemorrhage, the patients status as a type I or type II diabetic, the duration of the vision loss, presence of prior laser treatment, the impact on vision, and the overall health of the eye.
    • No Fixed Waiting Period: There is no fixed waiting period for the blood to clear before considering surgery. The decision is often based on the clinical judgment of the ophthalmologist.  It is common to wait one month in type I diabetics and six months in type II diabetic before considering surgery.  The presence of prior laser, which can be protective, is also considered when timing the surgery.
  3. Risks and Benefits:
    • Benefits: Vitrectomy can provide significant benefits by removing the blood from the vitreous cavity, allowing for improved visualization of the retina and restoration of vision. It may also prevent further complications associated with vitreous hemorrhage.
    • Risks: Risks of vitrectomy include infection, retinal detachment, increased intraocular pressure, and the development of cataracts. The overall risk-benefit assessment is made on a case-by-case basis.
  4. Procedure:
    • Anesthesia: Vitrectomy is typically performed under local or general anesthesia.
    • Small Incisions: Small incisions are made in the sclera (white part of the eye) to introduce microsurgical instruments.
    • Removal of Vitreous: The surgeon removes the cloudy vitreous gel containing blood from the eye.
    • Replacement: The removed vitreous is replaced with a clear saline solution or a gas bubble, depending on the specific situation.
    • Endoillumination and Visualization: The surgery often involves the use of an endoilluminator (light source) and a microscope for precise visualization of the retina.
    • Closing Incisions: The incisions are closed, and the eye is usually patched after surgery.
  5. Postoperative Care:
    • Recovery: The recovery period varies, but patients may need to limit activities and follow specific postoperative care instructions.
    • Follow-Up: Regular follow-up appointments are essential to monitor the healing process and address any concerns.

Vitrectomy is generally considered a safe and effective procedure for managing severe diabetic vitreous hemorrhage when indicated. However, like any surgery, it carries certain risks, and the decision to undergo vitrectomy should be made in consultation with an experienced retinal surgeon who can assess the specific circumstances of the patient.

It’s crucial for individuals with diabetes to maintain regular eye examinations to detect and manage diabetic retinopathy early, potentially preventing complications that could lead to the need for surgical intervention.

This case illustraites a surgery for a diabetic with a dense bleed in the vitreous. Toward the end of the surgery, the small 25 gauge cutter becomes blunt and needs to be replaced. The outcome was excellent.

65 Year Old woman with vision loss for almost 2 years. Her vision was light perception when she presented. Her fellow eye had mild proliferative diabetic retinopathy. This eye had a normal ultrasound (except for the vitreous hemorrhage). Her cataract was removed about 2 weeks prior to this surgery. Diabetic vitrectomies have slightly better outcomes if done subsequent to cataract surgery. This video shows the dense vitreous hemorrhage looks yellow white.