The case image shows abnormal echogenic (white) material just anterior to the optic nerve bulge at the bottom of the image, which is indicative of a vitreous hemorrhage. The next best step in treatment is to refer to ophthalmology and to pause any treatment with blood thinners. 

Vitreous hemorrhage is a potentially vision-threatening but treatable condition that may result from bleeding into the vitreous gel in the center of the eye. Risk factors for vitreous hemorrhage include the use of blood thinners, diabetic retinopathy, sickle cell disease, retinal detachment, and trauma to the eye.

The clinical presentation typically includes painless loss of vision combined with floaters. Ocular examination will reveal decreased visual acuity and an afferent pupillary defect may be present. Indirect ophthalmoscopy may reveal poor visualization of the retina.


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Testing for vitreous hemorrhage should include a complete blood count to check platelet count, chemistry to check renal function, coagulation tests, and tonometry.  Bedside ultrasound may also be useful especially if the retina is obscured by blood.

Ultrasound results typically show the presence of hyperechoic material within the vitreous, often most concentrated posteriorly, adjacent to retinal vessels.

Treatment includes bed rest with the head of bed elevated and control of triggers. All cases of vitreous hemorrhage should be referred urgently to an ophthalmologist. If conservative treatment is not successful, laser treatment of neovascularization or vitrectomy should be considered. 

This patient was seen by an ophthalmologist who temporarily paused her treatment with warfarin. The patient responded well.

Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Reference

Pregerson DB. Ophthalmology: Vitreous hemorrhage. In: Emergency Medicine 1-Minute Consult Pocketbook. http://www.erpocketbooks.com/emergency_medicine_reference_books/quick-essentials-emergency-medicine/. 2017;5.