A 32-year-old woman was doing cartwheels at a children's party, when she became dazzled in her right eye. She stopped and immediately noticed a positive central scotoma in this eye. She had congenital nystagmus and wore contact lenses to correct myopia. She had no other medical problems and was generally well with no bruising or blood loss reported. She took no medications and in particular, had no history of taking any anti-clotting agent such as aspirin or warfarin. There was no history of general or ocular trauma.
A day later she attended an ophthalmology clinic, where her visual acuities were 6/36 with pinhole in the amblyopic right eye and 6/9 in the left eye. On examination, a well-demarcated circular subhyaloid haemorrhage was noted in front of the right macula, presumed to be caused by a Valsalva effect. The peripheral right retina and the disc, macula and retinal periphery of the left eye were normal. Specifically, there were no angioid streaks or lacquer cracks, no cavernous or capillary haemangiomata and no degenerative changes or retinal breaks. No vitreous haemorrhage was evident. Retinal photography was performed.
Conservative management of subhyaloid haemorrhage is often appropriate. In some cases treatment might be needed for haemorrhages that fail to resolve or are catastrophically blocking vision and impeding activities of daily living, such as driving or working. Nd:YAG laser can puncture the posterior vitreous face and allow blood to dissipate in the vitreous body;1 however, there is a risk of complications, such as macular hole formation or retinal detachment. Also described2 is injection of tissue plasminogen activator into the vitreous body, followed by pneumatic displacement of blood with C3F8 gas and two weeks of face-down posturing.2 This option has the attendant risks of intraocular injection, including retinal detachment and endophthalmitis and posturing might be difficult for some.
In this case, options were discussed with the patient and conservative management was thought appropriate. The patient was not given any specific advice regarding posture. The blood settled due to gravity, causing the so-called ‘boat sign’ on examination, as shown in the photograph taken one month after presentation (Figure 1). Symptoms and signs resolved over several months. The final visual acuity was 6/18 with pinhole. A better visual recovery might have been prevented due to damage induced by the prolonged presence of blood.3