Definition

Retinal hemorrhage is bleeding that occurs in the retina, the innermost part of the eye, due to ruptured blood vessels. The retina, which is sensitive to light and composed of nerve cells, sends visual information to the brain via the optic nerve. The treatments are focused to slow or stop the bleeding. If not properly managed, retinal hemorrhage can cause permanent blindness. It is often a sign of other vascular diseases and can range from small spots of bleeding to more extensive hemorrhages.

Retinal hemorrhage is commonly observed in adults over 40 years old with systemic diseases like diabetes and hypertension. In children, it is often associated with systemic infections, brain trauma, and blood vessel abnormalities. Newborns can also experience retinal hemorrhage, whether from normal vaginal birth (25%), and particularly those born via caesarean section or other assisted delivery methods (40-50%). Retinal hemorrhage in children may also indicate domestic violence, especially in those under six months old.

Causes

Retinal hemorrhage can be caused by various factors, including:

• Eye diseases such as age-related macular degeneration (ARMD)
• Diabetic retinopathy
• Hypertensive retinopathy
• Retinal vein occlusion, which causes widespread retinal bleeding
• Trauma, occurring from events like the Valsalva maneuver or shaken baby syndrome; birth canal trauma can also cause retinal hemorrhage
• Anemia
• Leukemia
• Acute bacterial endocarditis
• Sickle cell anemia
• Preeclampsia
• Lupus
• Living at high altitudes (high altitude retinopathy)

Risk Factor 

Several factors increase the risk of retinal hemorrhage:

• Advanced age
• Smoking
• Obesity
• Having diabetes, hypertension, or other systemic diseases
• Eye trauma
• Family history of retinal diseases

Symptoms

Symptoms of retinal hemorrhage may include:

• Seeing black shadows or floating dots
• Blurred vision
• Damage to one side of the visual field
• Loss of vision

Diagnosis

When diagnosing retinal hemorrhage, your doctor will inquire about your eye-related symptoms, including their onset, whether they affect one or both eyes, and any associated risk factors such as smoking, high cholesterol, diabetes, and uncontrolled blood pressure. A family history of retinal disease will also be considered. The doctor will examine your retina using an ophthalmoscope or slit lamp, after administering eye drops to dilate your pupils. Additional tests that might be conducted to evaluate your retina include:

• Optical Coherence Tomography (OCT). Provides a detailed image of your retina, helps assess the condition of the macula, detect swelling, and monitor treatment response.
• Fundus Autofluorescence (FAF). Evaluates the severity of retinal disease by examining the pigment in retinal cells.
• Fluorescein Angiography. Uses special lighting to view retinal blood vessels. This examination is important in identifying neovascularization, broken vessels, and areas of bleeding.

Given that retinal hemorrhage is linked to systemic conditions, your doctor may also monitor your blood pressure, body mass index (BMI), and blood sugar levels before proceeding with further tests. Specific tests for underlying conditions of retinal hemorrhage might include:

• Diabetes and etmabolic syndrome: Complete blood count and HbA1c to assess blood sugar control over the past three months.
• Blood clotting disorders: Blood clotting panel.
• Infections: ELISA, FTA-ABS/RPR tests.
• Immune diseases such as SLE (Lupus): ANA and anti-ds DNA tests.

The procedures above are only performed as indications.

Management

The primary goal in managing retinal hemorrhages is to slow and stop the bleeding, thereby preserving retinal function. Early detection is crucial, especially if retinal damage is extensive and irreversible.

Treatment Procedures

Several treatments for retinal hemorrhage include:

• Laser treatments, the laser can 'shoot' at bleeding blood vessels in your retina or new blood vessels that may burst.a laser can 'shoot' a blood vessel bleeding on your retina or a new blood vessel that may burst. Laser photocoagulation uses lasers to target and seal bleeding blood vessels or new fragile vessels. This is common in diabetic retinopathy treatment. Laser photocoagulation can cause loss of some visual fields, especially peripheral vision and night vision. There are two types, focal photocoagulation that retinal tears and scatter photocoagulation that stops widespread bleeding.
• Vitrectomy, namely a surgical procedure to remove the vitreous fluid and replace it with a different fluid. This is used when bleeding affects the retina, as seen in cases of retinal tears, diabetic retinopathy, infections, and eye trauma.

If vitreous bleeding occurs, your doctor will recommend complete rest to prevent further bleeding. Eye patching may help minimize eye movement and localize the bleeding. Blood thinning medications may be temporarily discontinued.

Education

Retinal hemorrhage and associated vision loss can significantly impact your quality of life. The following strategies can help you adapt:

• Consult your doctor for prescription glasses to aid in your vision
• Modify computer settings and use audio tools to facilitate daily tasks.
• Use electronic devices like audiobooks to help in daily activities.
• Install brighter lights at home.
• Discuss with your doctor whether you can continue to drive.
• Join communities with similar experiences for emotional support.

Complications

Retinal hemorrhages in newborns and children due to birth canal injuries usually present minimal symptoms and can heal completely within 2–4 weeks. Retinal hemorrhages caused by metabolic conditions or vein occlusion can be managed by controlling underlying risk factors. Hemorrhages in the macular area can have severe symptoms and complications but may recover fully if treated promptly. Generally, retinal hemorrhages in adults can heal within three months.

Untreated retinal hemorrhages can lead to complications such as glaucoma, expansion of the hemorrhage, submacular fibrosis, retinal neovascularization (formation of new, fragile blood vessels that can cause recurrent hemorrhages), and permanent blindness.

Prevention

Preventive measures for retinal hemorrhage include:

• Controlling risk factors such as hypertension and diabetes
• Using eye protection when engaging in activities that risk eye injury

When to See a Doctor?

It's crucial to see a doctor if you experience any changes or symptoms in your vision. Immediate medical attention is needed if you see floating black shadows or notice a decrease in vision. Before visiting the doctor, note all vision-related complaints and the medications you are taking. If you have difficulty seeing, have a family member accompany you to the nearest health facility.

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