Retinal Hemorrhages: Etiologies, Diagnostic Approaches, and Management Strategies for Ocular and Systemic Disorders

Amer Hassan Mohammed Al-Shahri ^1*, Ali Mesfer Alkhathami ¹, Ali Jamal Faleh Al-Anzi ¹, Binselm, Khalid Rashad A ¹, Faleh Mohammed Al Dawsar ¹, Al Duheem, Bader Sughayir D ¹, Ahmad Ayad M Avaz ¹, Naif Munif Aldumayki Alotaibi ¹, Saleh Helayyil Saleh Alharbi ¹, Rayan Mohammed Mubarak Alotaibi ¹

Retinal hemorrhages are critical markers of ocular and systemic disease, requiring timely diagnosis and intervention to preserve vision.

Abstract

Retinal hemorrhages are pivotal clinical findings that signify a broad range of ocular and systemic pathologies, varying from benign to vision-threatening conditions. This review highlights the etiologies, clinical implications, diagnostic challenges, and emergency management strategies associated with retinal hemorrhages. A systematic analysis of peer-reviewed literature, clinical guidelines, and recent studies was performed, focusing on hemorrhage classification, pathophysiology, diagnostic approaches, and treatment protocols. Findings reveal that hemorrhage location critically influences prognosis and treatment strategies, with systemic diseases such as hypertension, diabetes, and coagulopathies accounting for 70% of adult cases. Nd:YAG laser membranotomy achieves up to 85% visual recovery in subhyaloid hemorrhages, while timely intervention within 7–14 days is crucial for submacular hemorrhages to prevent photoreceptor damage. Multidisciplinary management enhances outcomes in trauma- and abuse-related hemorrhages. Diagnostic imaging modalities like optical coherence tomography (OCT) and fundus fluorescein angiography (FFA), combined with targeted laboratory tests, are essential for accurate diagnosis. Ultimately, tailored management strategies based on anatomical and systemic contexts, coupled with prompt intervention, are critical for preserving vision and addressing underlying systemic disorders.

Keywords: retinal hemorrhage, submacular hemorrhage, vitreous hemorrhage, Terson syndrome, hypertensive retinopathy

References

Agrawal, S., Peters, M. J., Adams, G. G., & Pierce, C. M. (2012). Prevalence of retinal hemorrhages in critically ill children. Pediatrics, 129(6), e1388–e1396. https://doi.org/10.1542/peds.2011-2772

Binenbaum, G., Mirza-George, N., Christian, C. W., & Forbes, B. J. (2009). Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. Journal of AAPOS, 13(3), 268–272. https://doi.org/10.1016/j.jaapos.2009.03.005

Czorlich, P., Skevas, C., Knospe, V., Vettorazzi, E., Richard, G., Wagenfeld, L., Westphal, M., & Regelsberger, J. (2015). Terson syndrome in subarachnoid hemorrhage, intracerebral hemorrhage, and traumatic brain injury. Neurosurgical Review, 38(1), 129–136. https://doi.org/10.1007/s10143-014-0573-3

Duane, T. D. (1972). Valsalva hemorrhagic retinopathy. Transactions of the American Ophthalmological Society, 70, 298–313.

Hochman, M. A., Seery, C. M., & Zarbin, M. A. (1997). Pathophysiology and management of subretinal hemorrhage. Survey of Ophthalmology, 42(3), 195–213. https://doi.org/10.1016/S0039-6257(97)00086-4

Kanukollu, V. M., & Ahmad, S. S. (2023). Retinal hemorrhage. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560777/

Kaur, B., & Taylor, D. (1990). Retinal haemorrhages. Archives of Disease in Childhood, 65(12), 1369–1372. https://doi.org/10.1136/adc.65.12.1369

Kaur, B., & Taylor, D. (1992). Fundus hemorrhages in infancy. Survey of Ophthalmology, 37(1), 1–17. https://doi.org/10.1016/0039-6257(92)90002-9

Khawly, J. A., & Pollock, S. C. (1994). Litten's sign (Roth's spots) in bacterial endocarditis. Archives of Ophthalmology, 112(5), 683–684. https://doi.org/10.1001/archopht.1994.01090170129032

Kitagawa, Y., Shimada, H., Mori, R., Tanaka, K., & Yuzawa, M. (2016). Intravitreal tissue plasminogen activator, ranibizumab, and gas injection for submacular hemorrhage in polypoidal choroidal vasculopathy. Ophthalmology, 123(6), 1278–1286. https://doi.org/10.1016/j.ophtha.2016.01.035

Ling, R., & James, B. (1998). White-centred retinal haemorrhages (Roth spots). Postgraduate Medical Journal, 74(876), 581–582. https://doi.org/10.1136/pgmj.74.876.581

Liu, Z., Pan, X., & Bi, H. (2014). Treatment of Valsalva retinopathy. Optometry and Vision Science, 91(11), e278–e281. https://doi.org/10.1097/OPX.0000000000000403

Loughrey, P. B., Armstrong, D., & Lockhart, C. J. (2015). Classical eye signs in bacterial endocarditis. QJM, 108(11), 909–910. https://doi.org/10.1093/qjmed/hcv089

Maguire, S., Pickerd, N., Farewell, D., Mann, M., Tempest, V., & Kemp, A. M. (2009). Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Archives of Disease in Childhood, 94(11), 860–867. https://doi.org/10.1136/adc.2008.150110

Mennel, S. (2007). Subhyaloidal and macular haemorrhage: Localisation and treatment strategies. British Journal of Ophthalmology, 91(7), 850–852. https://doi.org/10.1136/bjo.2006.108571

Miguel, A. I., Henriques, F., Azevedo, L. F., Loureiro, A. J., & Maberley, D. A. (2013). Systematic review of Purtscher's and Purtscher-like retinopathies. Eye, 27(1), 1–13. https://doi.org/10.1038/eye.2012.222

Mills, M. (1998). Funduscopic lesions associated with mortality in shaken baby syndrome. Journal of AAPOS, 2(2), 67–71. https://doi.org/10.1016/S1091-8531(98)90067-1

Ozturker, Z. K., Munro, K., & Gupta, N. (2017). Optic disc hemorrhages in glaucoma and common clinical features. Canadian Journal of Ophthalmology, 52(6), 583–591. https://doi.org/10.1016/j.jcjo.2017.05.015

Sato, T., Morita, S., Bando, H., Sato, S., Ikeda, T., & Emi, K. (2013). Early vitreous hemorrhage after vitrectomy with preoperative intravitreal bevacizumab for proliferative diabetic retinopathy. Middle East African Journal of Ophthalmology, 20(1), 51–55. https://doi.org/10.4103/0974-9233.106388

Saxena, S., Jalali, S., Verma, L., & Pathengay, A. (2003). Management of vitreous haemorrhage. Indian Journal of Ophthalmology, 51(2), 189–196.

Uhler, T. A., & Piltz-Seymour, J. (2008). Optic disc hemorrhages in glaucoma and ocular hypertension: Implications and recommendations. Current Opinion in Ophthalmology, 19(2), 89–94. https://doi.org/10.1097/ICU.0b013e3282f3919b

Watts, P., Maguire, S., Kwok, T., Talabani, B., Mann, M., Wiener, J., Lawson, Z., & Kemp, A. (2013). Newborn retinal hemorrhages: A systematic review. Journal of AAPOS, 17(1), 70–78. https://doi.org/10.1016/j.jaapos.2012.09.009