List of Abbreviations
WHO – World Health Organization
ILM – internal limiting membrane
AMD – age-related macular degeneration
IOP – intraocular pressure
ONH – optic nerve head
PVD – posterior vitreous detachment
MD – medical devices
OCT – optical coherence tomography (optical examination of the retina using a computer analyzer)
OCT-A – optical coherence tomography angiography (optical examination of the retina using a computer analyzer in angiography mode)
PVR – proliferative vitreoretinopathy
PVRD – peripheral vitreochorioretinal dystrophies
RRD – rhegmatogenous retinal detachment
RPE – retinal pigment epithelium
SO – silicone oil
vitreous body
US – ultrasound examination
CRV – central retinal vein
EP – electrophysiological studies
** – Essential and vital drugs
Terms and Definitions
Ocular biomicroscopy is a method for the in vivo visual examination of the optical media and ocular tissues, based on creating contrast between illuminated and non-illuminated areas using a slit lamp and additional diagnostic ophthalmic lenses (in particular, for fundus biomicroscopy).
Retinal tear is any defect affecting the full thickness of the neurosensory retina. The clinical significance of a tear is that fluid from the vitreous cavity can penetrate into the space between the neurosensory retina and the retinal pigment epithelium (RPE), thereby causing rhegmatogenous retinal detachment (RRD).
Vitreous degeneration is an alteration in the structure of the vitreous body (VB) resulting from the disruption of bonds between hyaluronic acid and collagen fibers, leading to liquefaction of the VB (synchisis) and/or syneresis (compounding of the structure), which occurs as a result of many causes: involutional changes, surgical interventions, intraocular inflammation, eye trauma, and others.
Posterior vitreous detachment (PVD) is a process involving a series of physiological changes in the vitreous body (VB) that lead to the separation of the posterior cortical layers of the VB from the retina and optic nerve. It is one of the manifestations of involutional age-related changes. If PVD extends to the ora serrata, it can be considered complete.
Optical coherence tomography (OCT) (optical examination of the retina using a computerized analyzer) is a diagnostic, non-invasive, non-contact method for in vivo visualization and qualitative-quantitative analysis of the morphological features of fundus structures, based on the principle of light interferometry.
Proliferative vitreoretinopathy (PVR) is a pathological process accompanied by migration, transdifferentiation, and proliferation of various cell types, leading to the formation and growth of fibrous tissue on the surface of the retina, ciliary body, within the vitreous cavity, and subretinally.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Vitreous hemorrhage is a pathological condition developing as a result of the rupture of blood vessels and the extravasation of blood into the vitreous body (VB).
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
The problem of vitreous hemorrhage is one of the most complex and urgent in ophthalmology, as it can lead to conditions threatening the organ of vision (retinal detachment, toxic changes in the macular zone, etc.) [1, 2].
Among the causes of vitreous hemorrhage, 55% to 89.5% are attributed to proliferative diabetic retinopathy, eye trauma, and posterior vitreous detachment (with or without retinal tear formation). Vitreous hemorrhage can develop due to systemic diseases or ocular pathology. It may be caused by the rupture of normal blood vessels, bleeding from affected retinal vessels, bleeding from abnormal neovascular vessels, or the spread of hemorrhage into the vitreous through the retina from other sources [1–6].
Most commonly, hemorrhages from pathologically altered retinal vessels are caused by diabetic retinopathy, hypertensive retinopathy, retinopathies associated with blood diseases, rheumatic diseases, and other conditions [2, 6–8]. A large group consists of hemophthalmos developed against the background of central retinal vein occlusion (CRVO), intraocular vasculitis, dystrophies and retinal tears, and intraocular neoplasms [6, 8, 9, 10–13].
Despite the similarity of the clinical picture, the pathogenesis of vitreous hemorrhage varies significantly. In eye trauma, the source of hemorrhage is the direct destruction of ocular membranes with damage to blood vessels as a result of a penetrating wound, or their injury as a result of a contusion [14]. In diabetes mellitus, post-thrombotic retinopathy, age-related macular degeneration (AMD), and tumors, the source of hemorrhage is newly formed vessels, whereas in retinal tear and detachment, it is the native retinal vessels [1, 4, 15]. In addition to the above conditions proceeding with the development of intraocular hemorrhages, congenital and hereditary diseases, as well as shaken baby syndrome, are encountered, accompanied by hemorrhagic manifestations in the eye [16–20].
Pathogenetically, bleeding is always associated with a breach of vascular integrity. There are three mechanisms of bleeding: via rupture of the vessel wall; due to increased vascular permeability; and via enzymatic digestion of the vessel wall components. All three links of the hemostatic system (vascular, platelet, and plasma) are triggered almost simultaneously at the moment of vessel damage. Blood poured into the eye cavity (vitreous body) undergoes a series of changes: "blood clotting", formation of a blood clot, and activation of the fibrinolytic system—a protective mechanism preventing excessive fibrin deposition. During fibrinolysis (dissolution of the fibrin base of the blood clot), on the 2nd–3rd day after the hemorrhage, erythrocytes are released, which undergo hemolysis (destruction) and gradually become discolored. Hemoglobin, in turn, is split into heme and globin; the latter, together with other proteins of the decaying blood, causes a shift in the medium pH toward acidosis. Heme breaks down into iron and biliverdin, which leads to siderosis of surrounding tissues, and in recurrent hemorrhages, even to secondary hemochromatosis. The unabsorbed part of the blood clot undergoes organization with the potential formation of connective tissue. Knowledge of all stages of hemorrhage development is necessary to carry out pathogenetically justified treatment in optimal timeframes [1, 3, 7, 21, 22].
1.3 Epidemiology of the Disease or Condition
The social significance and urgency of the studied problem lie in the fact that vitreous hemorrhage is one of the polyetiological diseases of the visual organ that affects almost all age groups of patients, can occur in young, able-bodied people, arises suddenly, and its incidence increases with age [6, 8]. According to various authors, the prevalence of spontaneous vitreous hemorrhage in the general population is about 7 cases per 100,000 population, and in some populations 4.8 per 10,000 population per year, most commonly occurring at the age of 40 to 59 years [23, 24]. Among the causes leading to the development of this pathology, 34.1% account for diabetic retinopathy, 22.4% for retinal tear without retinal detachment, 14.9% for rhegmatogenous retinal detachment, 13% for retinal vein occlusion, and 16% for other conditions and diseases (posterior VB detachment, retinopathy of prematurity, uveitis, Terson syndrome, vasculitis, age-related macular degeneration, etc.) [6, 8]. Hemorrhages due to shaken baby syndrome account for 15–30 cases per 100,000 children under 1 year of age [6, 25, 26].
1.4 Features of Coding the Disease or Condition
H43.1 – Vitreous hemorrhage
1.5 Classification of the disease or condition
Classification of hemophthalmos proposed by V.V. Volkov et al. in 1990.
I. By cause:
Traumatic (primary vessel rupture in a penetrating wound, including surgery, severe ocular contusion);
Non-traumatic (due to dystrophy and delayed destruction of the vessel wall during impaired venous outflow from the eye cavity, inadequacy of newly formed retinal and choroidal vessels, with increased vascular permeability without its rupture);
II. By volume of hemorrhage:
Partial (less than 1/3 of the vitreous body),
Subtotal (from 1/3 to 2/3),
Total (more than 2/3 of the vitreous body).
III. By localization in eye segments:
- anterior,
- median,
- posterior,
- mixed.
IV. By localization relative to the eye walls:
- central,
- parietal,
- parieto-central.
V. By stages of hematoma evolution:
Stage I – fresh hematoma (several minutes – 48 hours),
Stage II – toxico-hemolytic stage (3–10 days),
Stage III – proliferative stage (10 days – 6 months),
Stage IV – fibrosis stage (more than 6 months).
Table 1. Classification of vitreous hemorrhage by stages of disease development (Volkov V.V., Danilov A.V., Rapis E.G., et al., 1990)
Grade | Time from disease onset | Main pathomorphological and pathophysiological signs |
|---|---|---|
1 | 2 | 3 |
Bleeding | From several seconds to 24 h | Inadequacy of the intraocular vessel wall, exit of blood or its elements beyond the vessel, focal disturbance of vitreous body transparency |
Fresh hematoma | From several minutes to 48 h | Clots of mostly already clotted red blood between or near vitreous structures in the absence of noticeable erythrocyte hemolysis and hemoglobin diffusion into the vitreous body, first signs of phagocytic reaction |
Toxico-hemolytic stage | 3–10 days | Rapidly increasing erythrocyte hemolysis with diffusion of hemoglobin and its breakdown products into the vitreous body and other intraocular structures (siderosis, acidosis, oversaturation with proteins and cholesterol); pronounced phagocytosis and increasing proliferation: diffuse opacification of the entire vitreous mass |
Proliferative-dystrophic | 10 days – 6 months | Diffuse hemosiderotic dystrophy of the vitreous body, retina, lens, and other intraocular structures; pronounced proliferation of the pigment epithelium, retinal neuroglia; connective tissue organization of the hematoma |
Intraocular fibrosis | More than 6 months | Membrane (vitreous strand) formation in the vitreous body with its liquefaction in some areas and compaction (in particular, crystal and bone formation) in others, irreversible retinal hemosiderosis, its detachment; phthisis and atrophy of the eyeball |
Table 2. Classification of vitreous cavity hematoma by localization (V.V. Volkov, 1990)
Retrolental | Between the anterior hyaloid membrane of the vitreous body and the posterior lens capsule |
|---|---|
Paraciliary | Surrounds the peripheral part of the lens posteriorly |
Preretinal | Between the posterior limiting membrane of the vitreous body and the retina |
Epimacular | In the cavity formed between the posterior limiting membrane and the retina in the macular region (vitreoschisis) |
Intravitreal | Within the vitreous cavity |
Combined | Occupies several areas of the vitreous body |
1.6 Clinical presentation of the disease or condition
With a small vitreous hemorrhage, the patient complains of the sudden appearance of a floating red or black spot (or spots), "floaters" before the eyes, cloud-like or cobweb-like shadows in the visual field. With more pronounced hemorrhages, the patient notes changes in the form of a marked decrease in vision down to light perception. If the cause of the hemophthalmos is traction from the vitreous body, complaints of phosphenes ("flashes of light" or "lightning") are possible due to mechanical stimulation of retinal ganglion cells by exfoliating cortical layers of the vitreous body [3,7,27]. Such symptoms are also precursors of rhegmatogenous retinal detachment (RRD).
In some cases, vitreous hemorrhage proceeds with ocular hypertension and complaints of eye pain.
Upon ophthalmoscopy, a localized vitreous hemorrhage appears as a dark (gray or whitish) floating clot of varying localization with/without alteration of the vitreous body structure. In partial hemophthalmos, red blood conglomerates floating with eye movements are visible in the vitreous body during the first two days. The remaining parts of the vitreous body may remain transparent. A few days later, fundus examination may be difficult due to hemolysis and the development of diffuse vitreous opacity. At the same time, a dense suspension of formed blood elements will be distinguishable in it, and blood clots will lose clear contours, the color of blood may also change. In late stages, a fundus reflex may appear, along with partial restoration of transparency of the vitreous body. Semi-fixed or freely floating white or translucent fibers (as a result of altered vitreous structure) may be detected at the hemorrhage site [7,10,16,27].
In subtotal and total hemophthalmos, ophthalmoscopy is not feasible. Biomicroscopically, it is possible to detect the presence of a scarlet or dark brown granular mass with a reddish tint, which impregnates the vitreous body. Details of the vitreous body structure are not defined. At the same time, the fundus reflex is absent. It is not possible to examine the deeper parts of the vitreous body [7,10,16,27]. In the organization stage, white connective tissue cords are detected. Most often they are fixed in the posterior pole area and cause retinal traction.
2. Diagnostics, medical indications and contraindications for diagnostic methods
In the event of a vitreous hemorrhage, the diagnosis must be established as soon as possible in order to determine the optimal patient management tactics and, if indications are present, provide surgical or laser intervention within the established timeframe to increase the effectiveness of treatment for this pathology.
An ophthalmologist, based on anamnestic data, patient examination, assessment of the clinical picture, and additional examination methods, verifies the condition according to ICD-10 criteria.
The clinical picture is the basis for diagnosing the disease. The symptoms and clinical signs indicated in clause 1.6 are the clinical criteria for establishing this disease: the presence of one or more blood clots in the vitreous body, fixed or freely floating, with/without fixed or translucent vitreous fibers or diffuse vitreous opacity with/without retinal tear, with/without retinal detachment, with/without proliferative vitreoretinopathy, with/without macular edema, with/without retinal hemorrhages, with/without choroidal detachment in the presence of a native lens or pseudophakia, established by ophthalmoscopy, eye biomicroscopy, and confirmed by B-scan ocular ultrasound.
It is recommended to perform an initial ophthalmologist consultation and examination (B01.029.001) for patients with hemophthalmos in order to diagnose the disease and determine treatment tactics [7,14,17,27,39,43].
Level of Evidence CGrade of Recommendation 5Level of Evidence C (reliability of evidence – 5)
2.1 Complaints and Anamnesis
It is recommended to collect anamnesis and complaints regarding eye pathology in all patients with suspected vitreous hemorrhage in order to determine the presence of functional visual disorders [3,4,6,7].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: there may be an absence of complaints in the early stages of the disease. Patients with vitreous hemorrhage may complain of the presence of recently appeared or enlarged "black dots" or "floaters", a dark spot/spots; floating clumps, strands, flashes, or photopsia, and complaints of a sharp decrease in vision down to light perception [3,7,27,28]. From the anamnesis data, it is important to clarify the duration of complaints, the presence of any general somatic diseases, hereditary diseases, episodes of heavy physical labor preceding the appearance of complaints, traumatic impacts, and previously performed surgical interventions on the organ of vision [3,28].
2.2 Physical Examination
Physical examination of patients to identify signs of vitreous hemorrhage is not used.
2.3 Laboratory Diagnostics
There are no diagnostic criteria for vitreous hemorrhage based on laboratory test results.
It is recommended to perform a general clinical blood test, general therapeutic biochemical blood test (study of total blood protein level, blood glucose level, blood urea level, blood creatinine level, blood albumin level, total blood bilirubin level, conjugated bilirubin level, blood aspartate aminotransferase activity, blood alanine aminotransferase activity, blood alkaline phosphatase activity, blood cholesterol level, coagulogram [exploratory hemostasis system test], general [clinical] urine test, determination of antibodies to Treponema pallidum by enzyme immunoassay [EIA] in blood, determination of Hepatitis B virus surface antigen [HBsAg] in blood, determination of antibodies to Hepatitis C virus in blood, determination of human immunodeficiency virus ribonucleic acid [RNA] by polymerase chain reaction [PCR], qualitative test) for patients with hemophthalmos when preparing for surgical treatment or for hospitalization for conservative treatment, to assess general status, identify comorbid conditions and possible contraindications to these types of treatment, and minimize the risk of complications [1,4,6,29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the examination is carried out on the basis of voluntary consent (Resolution of the Chief State Sanitary Doctor of the Russian Federation dated January 28, 2021 No. 4 (as amended on May 25, 2022) "On the approval of sanitary rules and norms SanPiN 3.3686-21 'Sanitary and epidemiological requirements for the prevention of infectious diseases'" (together with "SanPiN 3.3686-21. Sanitary rules and norms..." (Registered with the Ministry of Justice of Russia on February 15, 2021 No. 62500)).
The choice of laboratory test is determined depending on whether the patient has a concomitant systemic disease and risk factors for systemic complications.
2.4 Instrumental Diagnostics
It is recommended to perform visometry (A02.26.004) with full correction for all patients with vitreous hemorrhage at diagnosis and at each follow-up examination to monitor treatment in order to determine the severity of visual disorders [4,6,30].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform refractometry (A03.26.008) or determine refraction using a trial lens set (A02.26.013) for all patients with vitreous hemorrhage at diagnosis, follow-up, and treatment monitoring in order to determine the best corrected visual acuity for an accurate assessment of the severity of visual disorders [1,4,6].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform ophthalmotonometry (A02.26.015) (including under local anesthesia using a local anesthetic solution) for all patients with vitreous hemorrhage at diagnosis, follow-up, and treatment monitoring in order to detect intraocular pressure abnormalities [1,4,6,30].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
It is recommended to perform ocular biomicroscopy (A03.26.001), fundus biomicroscopy (A03.26.018), and/or peripheral fundus examination using a Goldmann three-mirror lens (A03.26.003), or indirect ophthalmoscopy (A02.26.003) of the peripheral retina (if biomicroscopy is impossible or difficult), including under conditions of pharmacological mydriasis (using anticholinergics and sympathomimetics, excluding antiglaucoma drugs, including fixed combinations), with scleral depression if necessary, in all patients with vitreous hemorrhage at all visits in order to detect intraocular changes, assess their severity, monitor status, and select the optimal management strategy [1,4,6,30].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: slit-lamp fundus biomicroscopy using non-contact diagnostic ophthalmic lenses (or ophthalmoscopy) is the primary method for diagnosing fundus changes in vitreous hemorrhage during an ophthalmological examination at any level of care (primary health care, specialized care) and setting (inpatient, outpatient). In patients with vitreous hemorrhage, it should be performed with a wide pupil (under conditions of pharmacological mydriasis) in the absence of contraindications. It is important to remember that the anterior chamber depth must be assessed prior to pharmacological pupil dilation.
Ophthalmoscopy is performed using a slit lamp with the patient in a sitting position at maximum achievable mydriasis using non-contact diagnostic ophthalmic lenses. To identify the location of a peripheral tear in complex or ambiguous cases, a peripheral fundus examination using a Goldmann three-mirror lens may also be performed. In addition, indirect binocular ophthalmoscopy is performed using a high-magnification lens for a detailed examination of fundus structures. The preferred patient position is supine, which creates optimal conditions for identifying potential fundus changes.
Examination of the retina typically begins at the superior segment in the region of the 12 o'clock meridian, gradually moving clockwise and examining the entire retina up to the ora serrata. The patient is asked to move their eyes and head to select the optimal viewing position. The detection of peripheral vitreoretinal degeneration, retinal tears, or retinal detachment influences the treatment strategy for the specific patient.
It is recommended to perform ocular ultrasound biometry (A04.26.004) to measure biometric parameters of the eye: anteroposterior axis, anterior chamber depth, and lens thickness in patients scheduled for lens replacement during surgery for vitreous hemorrhage in order to obtain data for accurate calculation of the artificial lens optical power during surgical treatment of the disease [1,4,6,30].
Level of Recommendations CLevel of Evidence 3Level of Recommendation C (Level of Evidence – 3)
It is recommended to perform optical examination of the retina using a computer analyzer (optical coherence tomography, OCT) (A03.26.019) under conditions of pharmacological mydriasis (using anticholinergics and sympathomimetics, excluding antiglaucoma drugs, including fixed combinations) (if technically feasible) in patients with vitreous hemorrhage when an in-depth assessment of the central zone is required during disease diagnosis, follow-up, and treatment monitoring, in order to quantitatively and qualitatively assess pathological changes in the central retinal zone and monitor treatment efficacy [4,6,31].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: Optical examination of the retina using a computerized analyzer should be performed under conditions of pharmacological mydriasis, as this significantly improves scan quality.
It is recommended to perform an ultrasound examination of the eyeball (A04.26.002) in B-scan mode in all patients with vitreous hemorrhage at the diagnostic stage, as well as in cases of suspected vitreoretinal interface disorders and membrane status during follow-up and treatment monitoring, in order to assess the position of the membranes and the spatial relationships of intraocular structures [3,4,6,32,36-39].
Level of confidence CLevel of evidence 4Level of confidence in the recommendations C (level of evidence – 4) – children
Level of confidence BLevel of evidence 2Level of confidence in the recommendations B (level of evidence – 2) – adults
It is recommended to perform static perimetry (A02.26.005) or automated computer perimetry (A03.26.020) in patients with vitreous hemorrhage when an in-depth study of the visual field is required during disease diagnosis, follow-up, and treatment monitoring, in order to assess retinal function and visual pathways [27,39-42].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform an electrophysiological study (recording of electrical sensitivity and labileness of the visual analyzer A05.26.003; electroretinography A05.26.001) in patients with vitreous hemorrhage when a detailed study of the degree of visual impairment and determination of the functional prognosis of surgery are required, in order to assess retinal function and visual pathways [39-41,49,50].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments: the decision to prescribe additional diagnostic methods is made by the physician based on the results of the baseline examination
2.5 Other Procedures
It is recommended to perform fundus biomicrophotography using a fundus camera (if technically feasible) in patients under conditions of pharmacological mydriasis (using anticholinergics and sympathomimetics, excluding antiglaucoma drugs, including fixed combinations) during disease diagnosis, follow-up, and treatment monitoring for screening, monitoring, and assessing treatment efficacy [6].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: the need for and frequency of fundus photography using a fundus camera is determined by the ophthalmologist depending on the course of the process. Fundus photography must be performed with a dilated pupil. Numerous studies have shown that pharmacological mydriasis significantly improves photograph quality. Therefore, fundus photography should currently be performed under conditions of pharmacological mydriasis regardless of the type of retinal camera [6].
It is recommended to perform optical examination of the retina using a computer analyzer in angiography mode (optical coherence tomography angiography, OCT-A) (if technically feasible) under conditions of pharmacological mydriasis (using anticholinergics and sympathomimetics, excluding antiglaucoma drugs, including fixed combinations) in patients with vitreous hemorrhage when retinal microcirculation impairment in the central fundus is suspected, in order to detect and monitor changes [1,4,6,30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: the need for and frequency of OCT-A is determined by the ophthalmologist depending on the course of the disease and the presence of comorbid conditions. Optical examination of the retina using a computer analyzer in angiography mode should be performed under conditions of pharmacological mydriasis, as this significantly improves the quality of the study.
Patients with concomitant and systemic diseases must be referred for consultation with relevant specialists as part of the management of the underlying disease and risk factors for various complications prior to laser or surgical treatment, in order to identify potential contraindications to these treatment modalities and minimize the risk of complications [4,27,28]. The choice of specialist profile (general practitioner, rheumatologist, endocrinologist, etc.) is determined by the concomitant systemic disease, its clinical course, and risk factors for systemic complications.
It is recommended to record an electrocardiogram (with decoding, description, and interpretation of electrographic data) in all patients with retinal detachment in preparation for surgical treatment or hospitalization for conservative treatment, in order to assess general status, identify comorbid conditions and potential contraindications to these treatment modalities, and minimize the risk of complications [6,29].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
Conservative treatment of hemophthalmos begins on the first day of the disease and continues for up to 2 weeks (in case of significant positive dynamics, it may be extended up to 1 month).
It is recommended to initiate treatment in patients with fresh hemophthalmos by prescribing angioprotectors (ATX code C05) and hemostatic agents (ATX code B02) to reduce the risk of recurrent hemorrhage [43,44,45].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: in the first 24 hours after the onset of hemophthalmus, angioprotective drugs (calcium dobesylate) and hemostatic agents (ethamsylate**) are prescribed to reduce the risk of recurrent hemorrhage.
Calcium dobesylate (C05BX01) – 500 mg 3 times a day for 2–3 weeks, then the dose is reduced to 500 mg once a day. For retinopathy and microangiopathy, 500 mg is prescribed 3 times a day for 4–6 months, then the daily dose is reduced to 500 mg once a day. Contraindicated in children under 18 years of age.
Ethamsylate** (B02BX01) – 0.25 g tablets. Single dose for adults is 0.25–0.5–0.75 g with a course of 5–14 days. For children, at a dose of 0.01–0.015 g/kg of body weight per day in 3 doses. For diabetic microangiopathy, intramuscularly at a single dose of 250–500 mg 3 times a day for 10–14 days for adults.
For surgical interventions: in adults – for prophylactic purposes, the drug is administered intravenously or intramuscularly 1 hour before surgery at a dose of 250–500 mg (2–4 ml), if necessary during surgery – at a dose of 250–500 mg (2–4 ml), and prophylactically – 500–750 mg (4–6 ml) intravenously or intramuscularly evenly over 24 hours after surgery. In children – if necessary during surgery, it is administered intravenously at a rate of 8–10 mg/kg of body weight.
It is recommended to prescribe other drugs that reduce capillary permeability (ATC code C05CX) to all patients with hemophthalmus for angioprotective purposes, for the resorption of hemorrhages, and other drugs for the treatment of ear and eye diseases (ATC code S03D) to prevent retinal damage by peroxidants, free radicals, and reactive oxygen species [44,45,46,47,51-55].
GPP CLOE 4Grade of Recommendation C (Level of Evidence – 4).
Comments:
Methylethylpyridinol (ATC code C05CX Other capillary stabilizing agents) – in the form of a solution for injection, eye drops subconjunctivally or parabulbar 0.5 ml once a day, course of treatment is 10–15 days. Contraindicated in children under 18 years of age.
Pentahydroxyethylnaphthoquinone (S03D Other ophthalmological and otological drugs) – is an antioxidant agent, available in the form of a solution for injection, prescribed as subconjunctival or parabulbar injections of 0.3–0.5 ml of a 0.2 mg/ml solution daily or every other day. Course of treatment is 5–10 injections. Contraindicated in children under 18 years of age.
In children, #pentahydroxyethylnaphthoquinone for grade 1 hemophthalmus: 0.02% solution parabulbar 0.3–0.5 ml daily, 10 injections per course, if necessary can be continued up to 15 injections. The most optimal administration of a 0.02% solution of #pentahydroxyethylnaphthoquinone is via an irrigation system (surgical ophthalmic system) – 0.3–0.5 ml from 2 to 4 times a day, course of treatment 10–15 days, if necessary up to 3 weeks [55].
It is recommended to use enzyme preparations (ATC code B01AD) on the 2nd–3rd day after the onset of hemophthalmus to accelerate the lysis of blood extravasated into the vitreous body [3,14,10,11,23,40,44,45,48].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comments: enzyme preparations enhance the lytic activity of the vitreous body, promote a longer liquid state of the extravasated blood, preventing its organization into a clot and accelerating the resorption of hemophthalmus. The drug of choice is prourokinase** (ATC code B01AD). Route of administration (subconjunctival, parabulbar, intravitreal). Contraindicated in patients under 18 years of age.
Prourokinase** (ATC code B01AD) – The contents of 1 ampoule of the drug are dissolved in 0.5 ml of 0.9% sodium chloride solution**. The resulting solution contains a dose corresponding to 5,000 IU. The drug is administered parabulbar or subconjunctivally up to 10 injections per course. For intravitreal administration, 5,000 IU of lyophilizate is dissolved in 1 ml of 0.9% sodium chloride solution**, 0.1 ml (500 IU) of the resulting solution is taken and diluted with 0.1–0.2 ml of 0.9% sodium chloride solution**. The resulting volume (0.2–0.3 ml) is administered intravitreally once.
If conservative treatment fails within two weeks, the issue of surgical treatment for hemophthalmus must be addressed.
3.2 Surgical Treatment
2–3 days prior to surgical treatment, antithrombotic agents (ATC code B01A) should be discontinued.
Microinvasive vitrectomy (A16.26.089) or vitreo-schwartectomy (A16.26.090) in an operating room using 23–27G technology under sub-Tenon's or retrobulbar anesthesia (using combined anesthesia if necessary), under drug-induced mydriasis (using anticholinergics and drugs from the pharmacotherapeutic group S01F Mydriatics and cycloplegics) is recommended; with disinfection of the eyelid skin, periocular area, and ocular surface using antiseptics and disinfectants (including iodine preparations) using antimicrobial agents (S01A). Use of concomitant manipulations if necessary, including phacoemulsification with intraocular lens implantation (A16.26.093.002) (The choice of IOL model depends on the clinical situation and may include: Posterior chamber intraocular lens, pseudophakic***, Iris-fixated intraocular lens***, Posterior chamber intraocular lens, pseudophakic, with extended depth of focus***, Anterior chamber intraocular lens, pseudophakic***, Intraocular lens with iridocapsular fixation***), membrane peeling (removal of the internal limiting membrane after preliminary staining of the internal limiting membrane using a dye (trypan blue)), temporary tamponade of the vitreous cavity with perfluorocarbon liquid, silicone oil, or a gas-air mixture [3,7,12,14].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
YAG-laser dissection of the posterior hyaloid membrane for subhyaloid hemorrhage is recommended to evacuate blood from the premacular bursa into the macular cavity [17,56-58].
LeR CLoE 4Level of Evidence/Recommendation Grade C (Level of Evidence – 4) – adults
GCR CLEL 5Level of Recommendation Credibility C (Level of Evidence – 5) – children
Comments: YAG-laser intervention on the posterior hyaloid membrane allows for the evacuation of blood from the premacular bursa into the vitreous cavity with subsequent conservative treatment.
Dietary therapy is not used for the treatment of patients with hemophthalmus.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
It is recommended to select low-vision optical correction aids (spectacles, including those with additional magnification and built-in monoculars, special information access devices for visually impaired disabled persons) (RZN 2016/4502) for patients after treatment of hemophthalmus who have uncorrectable visual acuity loss (low vision with BCVA of 0.1 and lower), in order to improve vision-related quality of life and social adaptation [18].
LeRR CLoE 4Level of recommendation confidence C (level of evidence – 4)
5. Prevention and Dispensary Observation
It is recommended to conduct regular dynamic follow-up: a repeat ophthalmologist appointment (examination, consultation) (B01.029.002) for patients after surgical treatment of hemophthalmus at 1 week, 1, 3, and 6 months, and dispensary ophthalmologist appointment (examination, consultation) (B04.029.001) to assess the condition of the visual organ and identify indications for therapeutic measures [3,27,40,48,53].
GCR CLEL 5Level of Recommendation Credibility C (Level of Evidence – 5)
Comments: After vitreoretinal surgery, standard follow-up intervals are: one day, one week, four weeks, three months, 6 months postoperatively; in the event of complications, the frequency of examinations increases. Subsequently, regular dynamic follow-up is advisable (repeat ophthalmologist appointment (examination, consultation), B01.029.002; dispensary ophthalmologist appointment (examination, consultation) B04.029.001) every 6–12 months with possible unscheduled examinations if any new visual disturbances appear.
To determine patients' subjective satisfaction with treatment outcomes, various assessment tools can be used, in particular the National Eye Institute Visual Function Questionnaire (NEI-VFQ 25) [33-35] (Appendix G).
6. Organization of Medical Care
Elective and emergency medical care is provided for hemophthalmus.
Primary specialized health care for adult patients with hemophthalmus is provided by an ophthalmologist in the outpatient department of a medical organization.
Treatment (laser intervention, conservative treatment) is carried out by an ophthalmologist on an outpatient basis, in a day hospital setting, or in an inpatient setting.
Indications for scheduled hospitalization in a medical organization:
1) the need for laser treatment and/or surgical treatment when outpatient treatment is not feasible;
2) the need to perform surgical interventions in a day hospital or inpatient setting.
Indications for discharging a patient from a medical organization:
1) completion of treatment or one of the stages of specialized, including high-tech, medical care in an inpatient or day hospital setting, provided there are no treatment complications requiring inpatient medical interventions;
2) refusal of the patient or their legal representative to receive specialized, including high-tech, medical care in an inpatient or day hospital setting;
3) need to transfer the patient to another medical organization.
7. Additional Information
Of particular importance is the prevention of vitreous hemorrhage and timely treatment of general systemic diseases [4, 23, 24].
It is necessary to inform the patient about the prognosis of the natural course of the disease in the absence of treatment, as well as the steady progression of anatomical and functional changes in vitreous hemorrhage up to complete vision loss. The patient must understand that the effectiveness of vitreous hemorrhage treatment largely depends on its timely administration [10].
Following laser or surgical treatment, the patient should be instructed on the recommended frequency of follow-up examinations by an ophthalmologist, depending on the clinical features, as well as the necessity of unscheduled examinations if any new visual disturbances occur.
If vitreoretinal surgery is performed for vitreous hemorrhage, the following points must be discussed with the patient:
it is important to warn the patient about the specifics of the postoperative course and potential ocular manifestations (irritation, eye redness, marked eyelid edema combined with copious discharge, eye pain, foreign body sensation behind the eyelids, unpleasant feeling when blinking, etc.), the severity of which depends on the specifics of the performed surgery and the patient's individual sensitivity;
it is important to explain to the patient that temporary glasses may be required during the rehabilitation period; final spectacle correction should ideally be performed no earlier than 2–3 months after surgery;
in the event of symptoms and changes characteristic of recurrent vitreous hemorrhage, the patient must be instructed on the need for an unscheduled examination by an ophthalmologist;
it is important to inform the patient about the gradual improvement of vision during the postoperative period;
it is important to warn the patient about adhering to the postoperative regimen (temporary restriction of activity, specific bedrest requirements), as this may have a certain therapeutic significance;
it is important to warn patients of the need to immediately report symptoms that may suggest intraocular inflammation (endophthalmitis): eye pain or increased discomfort in the eye, increased eye redness, blurred or decreased vision, increased photosensitivity, or an increased number of "floaters" in the visual field.
The patient must be informed about the necessity of normalizing blood pressure and other parameters prior to surgical treatment for vitreous hemorrhage. Furthermore, the patient must be encouraged to strictly comply with all prescriptions from specialists (ophthalmologist, cardiologist, general practitioner, endocrinologist, general practice physician/family doctor, etc.).
In the event of irreversible blindness or low vision, the patient must be fully informed about the opportunities for vocational, social, and psychological rehabilitation.
Criteria for Evaluating the Quality of Medical Care
No. | Quality criteria | Evaluation of compliance |
|---|---|---|
1 | Uncorrected and best-corrected visual acuity testing (visometry) was performed at diagnosis and at each follow-up examination. | Yes/No |
2 | Refractometry was performed during disease diagnosis, dynamic monitoring, and treatment control. | Yes/No |
3 | Ophthalmotonometry (including under local anesthesia using a local anesthetic solution) was performed during disease diagnosis, dynamic monitoring, and treatment control. | Yes/No |
4 | Eye biomicroscopy was performed at all visits. | Yes/No |
6 | Fundus biomicroscopy and/or ophthalmoscopy, including under medicated mydriasis, was performed at all visits. | Yes/No |
7 | B-scan ultrasonography of the eyeball was performed during disease diagnosis, dynamic monitoring, and treatment control. | Yes/No |
8. | Conservative treatment and/or intravitreal administration of medicinal products (A16.26.086.001) from the enzyme preparation group and/or YAG-laser treatment and/or surgical intervention (microinvasive subtotal vitrectomy (A16.26.089) / vitreoschisis removal / vitreoschwartenectomy (A16.26.090)) were performed when indicated and in the absence of medical contraindications. | Yes/No |
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Appendix A1. Working Group Composition
Arsyutov Dmitry Gennadievich – Candidate of Medical Sciences, General Director of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC
Ankudinova Svetlana Viktorovna – Candidate of Medical Sciences, Methodologist Physician at the St. Petersburg Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of the RF, Associate Professor of the Department of Dentistry and Maxillofacial Surgery at the Institute of Medical Education of the V.A. Almazov National Medical Research Centre of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC.
Boyko Ernest Vitalievich – Doctor of Medical Sciences, Professor, Corresponding Member of the Military Medical Academy, Director of the St. Petersburg Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, Head of the Department of Ophthalmology at the I.I. Mechnikov North-Western State Medical University of the Ministry of Health of Russia, First Deputy Chairman of the "Society of Ophthalmologists of Russia" LLC.
Voskresenskaya Anna Aleksandrovna – Candidate of Medical Sciences, Deputy Director for Research at the Cheboksary Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC.
Gorshkov Ilya Mikhailovich – Candidate of Medical Sciences, Head of the Vitreoretinal Department at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Kakunina Svetlana Aleksandrovna – Candidate of Medical Sciences, Researcher at the Department of Vitreoretinal Surgery and Diabetic Eye Disease at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Kolesnik Anton Igorevich – Candidate of Medical Sciences, Researcher at the Department of Vitreoretinal Surgery and Diabetic Eye Disease at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Kolesnik Svetlana Valerievna – Candidate of Medical Sciences, Researcher at the Department of Vitreoretinal Surgery and Diabetic Eye Disease at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Lyskin Pavel Vladimirovich – Doctor of Medical Sciences, Head of the Department of Vitreoretinal Surgery and Diabetic Eye Disease at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Norman Kirill Sergeevich – Candidate of Medical Sciences, Researcher at the Department of Vitreoretinal Surgery and Diabetic Eye Disease at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Pomytkina Natalia Viktorovna – Candidate of Medical Sciences, Head of the Scientific Department, Ophthalmologist at the Laser Surgery Department of the Khabarovsk Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC.
Sidorova Yulia Aleksandrovna – Candidate of Medical Sciences, Head of the Laser Surgery Department for Fundus Pathology of the Kaluga Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC.
Sorokin Evgeny Leonidovich – Doctor of Medical Sciences, Professor, Deputy Director for Research at the Khabarovsk Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, Honored Doctor of the RF, Honored Scientist of Khabarovsk Krai, member of the Society of Ophthalmologists of Russia, Academician of the Russian Academy of Laser Sciences.
Frolychev Ivan Aleksandrovich – Candidate of Medical Sciences, Deputy Director for Clinical Work at the Cheboksary Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC.
Khodzhaev Nazrulla Sagdullaevich – Doctor of Medical Sciences, Professor, Deputy General Director for Research at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, Deputy Chairman of the "Society of Ophthalmologists of Russia" LLC, Honored Doctor of Russia.
Shkvorchenko Dmitry Olegovich – Candidate of Medical Sciences, Deputy Chief Physician for Medical Affairs at the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia.
Yudina Nina Nikolaевна – Candidate of Medical Sciences, Head of the 2nd Ophthalmological Department of the Kaluga Branch of the S.N. Fedorov National Medical Research Center "Eye Microsurgery" of the Ministry of Health of Russia, member of the "Society of Ophthalmologists of Russia" LLC.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Ophthalmologists;
General practitioners (family physicians)
Medical students, residents, and postgraduate students.
Methods used for collecting/selecting evidence: search in electronic databases; analysis of modern scientific developments on the problem of rhegmatogenous retinal detachment in Russia and abroad; synthesis of practical experience of Russian and foreign specialists. Description of methods used for collecting/selecting evidence: the evidence base for the recommendations includes publications included in the Cochrane Library, EMBASE, and MEDLINE databases, as well as monographs and articles in leading specialized peer-reviewed domestic medical journals on this topic. Methods used for assessing the quality and strength of evidence: expert consensus, significance assessment in accordance with the rating scheme.
Table 1. Scale for grading levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic review of randomized clinical trials using meta-analysis |
2 | Individual studies with reference standard control or individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials, using meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, rehabilitation interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of randomized controlled trials with meta-analysis |
2 | Individual randomized clinical trials and systematic reviews of studies of any design, except for randomized clinical trials using meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
C | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The clinical guidelines update mechanism provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
Current instructions for the medicinal products mentioned in these clinical guidelines are published on the website http://grls.rosminzdrav.ru.
These clinical guidelines were developed taking into account the following documents:
Order of the Ministry of Health of the Russian Federation No. 558n dated June 9, 2020, "On Amendments to the Procedure for Providing Medical Care to the Adult Population for Diseases of the Eye, Its Adnexa, and Orbit".
International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) (World Health Organization) 1994.
Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services".
Federal Law No. 323-FZ of November 21, 2011, "On the Fundamentals of Health Protection of Citizens in the Russian Federation."
Order of the Ministry of Health of the Russian Federation No. 902n dated November 12, 2012 (as amended on February 1, 2022), "On Approval of the Procedure for Providing Medical Care to the Adult Population for Diseases of the Eye, Its Adnexa, and Orbit".
Order of the Ministry of Health of the Russian Federation No. 205n dated May 2, 2023 (as amended on December 4, 2023), "On Approval of the Nomenclature of Positions of Medical Workers and Pharmaceutical Workers".
Decree of the Government of the Russian Federation No. 2406-r dated October 12, 2019, "On Approval of the List of Vital and Essential Drugs, as well as Lists of Drugs for Medical Use and the Minimum Assortment of Drugs Required for the Provision of Medical Care"
Management of elective hospitalization in a multidisciplinary hospital. Methodological recommendations No. 2001/144: (approved by the Ministry of Health of the Russian Federation on 09.11.2001).
Order of the Ministry of Health and Social Development of the Russian Federation No. 786n dated December 29, 2008, "On the Procedure for the Formation and Approval of the State Assignment for the Provision of High-Tech Medical Care to Citizens of the Russian Federation at the Expense of Federal Budget Appropriations in 2009".
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
Nowadays, medicine is paying increasing attention to informing patients and their families about diseases. A lack of information, insufficient awareness regarding treatment options, recommended timelines for surgical interventions, and potential complications can cause various emotional reactions such as anxiety, reactive depression, and conflict behavior, which may lead to non-compliance with medical prescriptions and recommendations, and subsequent dissatisfaction with the treatment received.
International practical experience has demonstrated that a timely clinical diagnosis and appropriate surgical treatment for this pathology ensure a favorable prognosis and the preservation of visual function quality. The patient should be aware that laser treatment may require repeated treatment sessions, the frequency and scope of which are determined by the physician.
Following the surgical intervention, the patient will be briefed on the specifics of the rehabilitation period and the recovery of visual functions. They will be advised to continue treatment on an outpatient basis, which includes instillation of medications to prevent inflammatory phenomena in the organ of vision and taking agents that promote the restoration of impaired functions. The patient must follow a specific regimen (a certain head position, temporary restriction of activity, specific bed rest requirements) following surgery, which may have a definite therapeutic significance. Individual recommendations should be clarified during a doctor's consultation. The medical worker must inform patients who have undergone surgery regarding hemophthalmos, strict restriction of physical activity, visiting bathhouses or saunas for a month after surgery, and playing sports for a month after surgery. Subsequently, a slight increase in physical activity is possible only after consultation with the attending physician. In the postoperative period, the patient will be informed of the recommended frequency of examinations by an ophthalmologist depending on the severity of the clinical picture, as well as the need for unscheduled examinations upon the appearance of any new visual disorders. The patient must strictly follow all medical recommendations.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1
Russian title: National Eye Institute Visual Function Questionnaire
Original title (if available): The National Eye Institute Visual Function Source (official developer website, validation publication): [33-35]
Type (underline):
rating scale index questionnaire
Purpose: patient's subjective assessment of visual functions
Assessment tool, content:
Russian version of the NEI-VFQ 25 questionnaire [84, 85]
1. Overall, would you say your health is:
excellent.......................... 1
very good...................2
good..............................3
fair..........................4
poor.................................5
2. At the present time, would you say your vision in both eyes (with glasses or contact lenses, if you use them) is excellent, good, fair, poor, or very poor?
excellent.........................1
good..............................2
fair..........................3
poor.................................4
very poor......................5
completely blind.............6
3. How often do you worry about your eyesight?
never.......................................... 1
rarely............................................... 2
sometimes............................................. 3
often............................................... 4
constantly....................................... 5
4. How much pain or discomfort do you experience in and around your eyes (e.g., burning, itching, or an aching pain)?
none...................... 1
mild................. 2
moderate.......................... 3
severe.............................. 4
very severe.................. 5
5. How much difficulty do you have reading ordinary print in a newspaper?
not at all difficult....................................................... 1
a little difficult.......................................................... 2
quite difficult....................................................... 3
extremely difficult................................................. 4
stopped doing this due to vision......................... 5
stopped doing this for other reasons or not interested........................... 6
6. How much difficulty do you have doing work or hobbies that require you to see well up close, such as cooking, sewing, minor household repairs, or using hand tools?
not at all difficult....................................................... 1
a little difficult.......................................................... 2
quite difficult....................................................... 3
extremely difficult................................................. 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................. 6
7. Because of your eyesight, how much difficulty do you have finding something on a shelf crowded with items?
not at all difficult...................................................... 1
a little difficult........................................................ 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................ 6
8. How much difficulty do you have reading street signs, traffic signs, or store names?
not at all difficult........................................................ 1
a little difficult........................................................... 2
moderately difficult......................................................... 3
extremely difficult................................................... 4
stopped doing this due to vision......................... 5
stopped doing this for other reasons or not interested............................... 6
9. Because of your eyesight, how much difficulty do you have stepping down steps, stairs, or curbs in dim light or at night?
not at all difficult....................................................... 1
a little difficult.......................................................... 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight...................... 5
stopped doing this for other reasons or not interested............................ 6
10. Because of your eyesight, how much difficulty do you have noticing objects off to the side while walking?
not at all difficult....................................................... 1
a little difficult........................................................... 2
quite difficult....................................................... 3
extremely difficult................................................. 4
stopped doing this because of eyesight........................ 5
stopped doing this for other reasons or not interested.............................. 6
11. Because of your eyesight, how much difficulty do you have seeing how people react to things you say?
not at all difficult...................................................... 1
a little difficult.......................................................... 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................. 6
12. Because of your eyesight, how much difficulty do you have picking out and matching your clothes?
not at all difficult...................................................... 1
a little difficult......................................................... 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................. 6
13. Because of your eyesight, how much difficulty do you have visiting with people in their homes?
not at all difficult...................................................... 1
a little difficult......................................................... 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................. 6
14. Because of your eyesight, how much difficulty do you have going to movies, plays, or sporting events?
not at all difficult...................................................... 1
a little difficult......................................................... 2
moderately difficult...................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................. 6
15. If you currently drive: how much difficulty do you have driving during the day in familiar places?
not at all difficult....................... 1
a little difficult.......................... 2
moderately difficult........................ 3
extremely difficult.................. 4
16. How much difficulty do you have driving at night in familiar places?
not at all difficult...................................................... 1
a little difficult........................................................ 2
quite difficult....................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight...................... 5
stopped doing this for other reasons or not interested............................ 6
16a. How difficult is it for you to drive in difficult conditions, such as bad weather, rush hour, highways, or city traffic?
not at all difficult..................................................... 1
a little difficult........................................................ 2
quite a bit of difficulty..................................................... 3
extremely difficult................................................ 4
stopped doing this because of eyesight....................... 5
stopped doing this for other reasons or not interested............................ 6
17. Because of your eyesight, do you accomplish less than you would like?
All of the time.............. 1
Most of the time...................... 2
Some of the time.................... 3
A little of the time...................... 4
None of the time................. 5
18. Because of your eyesight, are you limited in how long you can work or do other activities?
All of the time............. 1
Most of the time..................... 2
Some of the time.................. 3
A little of the time..................... 4
None of the time................. 5
19. How often do you have to give up things you would like to do because of pain or discomfort in and around your eyes, such as burning, itching, or an aching pain?
All of the time............. 1
Most of the time..................... 2
Some of the time.................. 3
A little of the time..................... 4
None of the time................. 5
20. Because of my eyesight, I stay home most of the time:
definitely true............................. 1
mostly true............................. 2
not sure............................................. 3
mostly false.......................... 4
definitely false.......................... 5
21. Because of my eyesight, I often feel frustrated and annoyed:
definitely true............................. 1
mostly true............................. 2
not sure............................................. 3
mostly false.......................... 4
definitely false.......................... 5
22. Because of my eyesight, I have much less control over what I do:
definitely true............................. 1
mostly true............................. 2
not sure............................................. 3
mostly false........................... 4
completely untrue........................... 5
23. Because of my eyesight, I have to rely too much on what other people tell me:
definitely true............................. 1
mostly true............................. 2
not sure............................................. 3
mostly false........................... 4
completely untrue........................... 5
24. Because of my eyesight, I frequently need help from other people:
definitely true............................. 1
mostly true............................. 2
not sure............................................ 3
mostly false........................... 4
completely untrue........................... 5
25. I worry that because of my eyesight, I might do something that will embarrass myself or others:
definitely true............................. 1
mostly true............................. 2
not sure............................................ 3
mostly false........................... 4
completely untrue........................... 5
Interpretation:
All questions in the questionnaire are grouped into blocks assessing the patient's physical, mental, and social functioning in relation to their visual quality of life. The total score across all sections of the method allows for assessing the degree of reduction in the patient's quality of life relative to their visual functions.