Review Question - QID 214388

This patient is presenting with hazy vision, flashes of light, and an ultrasound demonstrating blood in the eye (white/hazy opacity on ultrasound), which are concerning for a vitreous hemorrhage.

Vitreous hemorrhage occurs when there is bleeding into the vitreous humor of the eye. Normally, the vitreous humor keeps the retina in place; however, traction at its attachment points can lead to bleeding. Diabetes can increase the risk of vitreous hemorrhage as it can lead to weak vessels that bleed more easily. Other risk factors include trauma, sickle cell disease, and advanced age. Assessment of this condition involves performing a visual acuity exam, testing for clotting factors, fundoscopy, and ultrasound. Treatment is to avoid anticoagulants/NSAIDs and treatment of the underlying cause. Supportive care should be provided for the patient in order to deal with the effects of transient loss of vision.

Wakabayashi et al. studied the rate of complications in patients treated with vitrectomy who were injected with dexamethasone or triamcinolone. They found that patients who were injected with triamcinolone had lower rates of ocular hypotony. They recommend using rotating injection sites or using sites other than the inferotemporal quadrant.

Figure/Illustration A is an ocular ultrasound with bright white specks representing blood in the eye (red arrows). If the patient looks left and right, the white specks will move around with a "dishwasher appearance" which is the sloshing of blood/hyperdense particles with motion that can be seen on ultrasound.

Incorrect Answers:
Answer 1: Multiple sclerosis can cause optic neuritis, which presents with sudden onset unilateral painful vision loss typically in a young woman who may have other neurological deficits such as speech difficulties, weakness, numbness, or urinary incontinence. An enlarged optic nerve would be seen on ultrasound. Patients can be treated with immunomodulators such as natalizumab or steroids for acute flares.

Answer 2: Retinal detachment presents with sudden onset vision loss like a "curtain is coming down" over the eye. An ultrasound would demonstrate a flap in the eye rather than the dishwasher finding (sloshing of blood/hyperdense particles with motion of the eye on ultrasound) as seen in this patient. Retinal detachment can often present with a concomitant vitreous hemorrhage.

Answer 3: Temporal arteritis presents with a headache, temporal tenderness, and blurry vision typically in an elderly patient. It is not typically associated with flashes of light. Patients should promptly be started on steroids followed by a temporal artery biopsy to confirm the diagnosis. Steroids precede confirmation of the diagnosis to reduce the incidence of vision loss.

Answer 4: Transient ischemic attack (TIA) presents with a sudden onset of neurological deficits that resolve spontaneously. This patient's visual abnormalities are persistent, and there are ultrasound findings supporting a diagnosis of vitreous hemorrhage. A TIA still requires workup with a CT, CTA head/neck, MRI, and labs to risk stratify the patient (such as lipids and hemoglobin A1c).

Bullet Summary:
A vitreous hemorrhage presents with sudden and painless vision loss with flashers/floaters and a "dishwasher" finding on ocular ultrasound.