The patient had a large subhyaloid hemorrhage, as well as a smaller vitreous hemorrhage.
There are many causes of preretinal hemorrhaging, which is often subhyaloid in younger patients who have not had separation of the posterior hyaloid face. Our patient denied straining at the time of the incident, but it was possible that Valsalva retinopathy could explain the hemorrhage. Perhaps the history was inaccurate, or perhaps she sneezed or coughed hard prior to bleed. Another leading diagnostic consideration is a congenital vascular anomaly that spontaneously bled. It would be unusual, but not impossible, for someone her age without a significant past medical history to have a retinal artery macroaneurysm or neovascularization, for example from a branch retinal vein occlusion.
Subhyaloid hemorrhages generally do not resolve in a timely fashion. We did vitrectomy to remove the blood, and the patient had excellent post-operative vision. Interestingly, there were no remarkable vascular findings, indicating that the underlying cause was likely Valsalva retinopathy.