Retinal Bleeding (Retinal Hemorrhages): Types & When to See a Doctor

Retinal bleeding, or a retinal hemorrhage, involves bleeding of the blood vessels in the retina. 

These are the four most common types of retinal hemorrhages:

• Subhyaloid and preretinal hemorrhage 
• Flame-shaped hemorrhage
• Dot and blot hemorrhage
• Subretinal and subretinal pigment epithelium (RPE) hemorrhages 

You should see your doctor immediately if you experience retinal bleeding or if you believe that you may be suffering from a hemorrhage. 

What Is a Retinal Hemorrhage?

A retinal hemorrhage occurs when there is bleeding within the blood vessels of the retina. This can be an indication of an ocular or systemic disease, such as diabetes. This hemorrhaging can also occur due to injury to the blood vessels, such as an injury to the head.

This condition can lead to many negative outcomes, including permanent vision loss. This condition can be pain-free. A comprehensive eye exam, along with further evaluation, is usually necessary to determine the underlying cause.

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Types of Retinal Hemorrhages

The following are the most common types of retinal hemorrhages:

Subhyaloid & Preretinal hemorrhages

These are also referred to as D, or boat-shaped, retinal hemorrhages. 

Subhyaloid hemorrhages are found between the posterior vitreous base and the internal limiting membrane. Preretinal hemorrhages are found posterior to the internal limiting membrane and anterior to the nerve fiber layer. 

Possible causes of these types of retinal hemorrhages include the following

• Posterior vitreous detachment and retinal breaks that lead to tearing of the major retinal vessels.
• Retinal trauma
• Retinal neovascularization
• Terson’s syndrome (subarachnoid and vitreous hemorrhaging)

Flame-Shaped Hemorrhages 

These are also referred to as linear retinal or feathered hemorrhages. Flame-shaped hemorrhages are located within the nerve fiber layer. They typically resolve within about six weeks. 

Possible causes of these hemorrhages include the following:

• Papilledema
• Hypertensive retinopathy
• Anterior ischemic optic neuropathy
• Normal-tension glaucoma
• Retinal vein occlusions

Dot and Blot Hemorrhages

These types of hemorrhages are also referred to as round retinal hemorrhages. They are located in the outer plexiform and inner nuclear layers, and their healing time is longer than it is for flame-shaped hemorrhages. 

Possible causes of these types of hemorrhages include the following:

• Ocular ischemic syndrome
• Vein occlusion
• Idiopathic juxtafoveal retinal telangiectasis (abnormal blood vessels at the center of the retina)
• Diabetic retinopathy

RPE Hemorrhages

These are also referred to as dark color retinal hemorrhages. They are located beneath the neurosensory retina, and they take the longest time to resolve of the four major hemorrhage types. 

There are two subtypes of this form of retinal hemorrhage:

1. Sub-RPE hemorrhage: This type of hemorrhage is located between the RPE and Bruch’s membrane. It has well-defined borders due to the cell junctions that exist between RPE cells.
2. Subretinal hemorrhage: This is a hemorrhage that occurs in the space between the retinal pigment epithelium and the neurosensory retina. These hemorrhages have an amorphous shape because of the lack of solid attachment between the RPE and neurosensory retina. 

Possible causes of subretinal and RPE hemorrhages include the following:

• Trauma
• Wet age-related degeneration of the macula
• RPE or neurosensory detachment
• Choroidal tumors
• Choroidal neovascular formation of the membrane

Symptoms of a Retinal Bleed

Some common symptoms of a retinal hemorrhage include the following:

• Sudden loss of vision
• Red tint in vision
• Vision that is distorted
• Floaters in the visual field
• Sudden flashes of light within the peripheral vision
• Shadows or hazy vision
• Seeing cobwebs
• Blurred vision
• Headache

Risk Factors

The following factors can increase your risk of experiencing a retinal hemorrhage:

• Retinal vascular disease
• Diabetes
• Anemia
• Posterior vitreous attachment
• Normal-tension glaucoma
• Hypertension
• Optic neuropathy
• Primary open-angle glaucoma

Causes of Retinal Bleeding

Retinal bleeding is most commonly caused by injury or trauma, such as the following:

• Falls from high locations
• Violent attacks
• Car accidents
• Sport-related accidents

In cases of retinal hemorrhaging that are specifically related to head trauma, any accident or injury can cause the hemorrhage. This hemorrhage can result if infants or small children are shaken, as in shaken baby syndrome. 
In non-injury cases, researchers have discovered that among the most common causes for retinal hemorrhaging include the following:

• Diabetic retinopathy
• Retinal vein occlusion
• Ocular ischemic syndrome
• Sickle cell retinopathy
• Hypertensive retinopathy
• Anemia
• Leukemia
• Acute bacterial endocarditis
• Preeclampsia
• High altitude retinopathy
• Connective tissue disorders 
• Ocular diseases, such as age-related macular degeneration, juxta foveal telangiectasia, or polypoidal vasculopathy

Treatment of Retinal Hemorrhages

First, a diagnosis is necessary. In order to achieve a diagnosis, appropriate testing is necessary. 

In addition to a comprehensive eye exam, your eye doctor may perform these tests:

• B-scan ultrasonography
• Dilated eye examination
• Slit-lamp examination
• Intraocular pressure test
• Gonioscopy

Retinal hemorrhages that are mild in nature and not associated with a chronic disease are generally resolvable without treatment or intervention. 

Treatment will ultimately depend upon the underlying cause of the bleeding. Laser surgery is an option in many cases involving trauma or injury. It is used to seal off blood vessels that have been damaged. 

Some additional treatments for a retinal hemorrhage include the following:

• Vitrectomy: This is the removal of some or all of the vitreous from the middle portion of the eye. 
• Intravitreal injection: This involves directly injecting medication into the vitreous.
• Cryotherapy: This involves freezing the retina back into its proper position following a hemorrhage. It can also effectively stop bleeding.
• Laser photocoagulation: This type of eye surgery is used to destroy or shrink abnormalities in the retina. 

Prevention of Retinal Hemorrhages

The following are ways to protect yourself and potentially prevent a first-time or recurrent hemorrhage of the retina:

• If you are playing an impact sport, use proper protective head gear and eyewear. 

• If you work in a field in which there is potential physical risk to your head or eyes, take necessary safety precautions and wear appropriate safety gear at all times. 

• If you have, or are at risk of, one of the diseases or conditions associated with a retinal hemorrhage, adhere to your doctor’s advice and care plan to reduce this risk. For example, if you have diabetes, follow all your doctor’s advice to maintain control of your blood sugar, blood pressure, and cholesterol.

If you have already experienced a retinal hemorrhage, you can help to prevent recurring hemorrhages via cryotherapy of the sclerotomy and other treatment approaches.

References

1. Preventing Recurrent Vitreous Hemorrhage. (December 2006). Ophthalmology.

2. Retinal Hemorrhage. (2016). Forensic Epidemiology.

3. Retinal Hemorrhage. (August 2022). StatPearls. 

4. Risk Factors Associated With Retinal Hemorrhage n Suspected Abusive Head Trauma. (April 2015). Journal of the American Association for Pediatric Ophthalmology.

5. Retinal Hemorrhages in Shaken Baby Syndrome. (April 2019). The Journal of Pediatrics.

6. Retinal Cryotherapy in Diabetic Vitreous Hemorrhage. (2013). Sudanese Journal of Ophthalmology.

7. Current Management of Vitreous Hemorrhage Due to Proliferative Diabetic Retinopathy. (Spring 2014). International Ophthalmology Clinics.