Traumatic hyphema: Difference between revisions
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==Background== | ==Background== | ||
*Grossly visible blood in the anterior chamber of the eye | *Grossly visible blood in the anterior chamber of the eye | ||
*Typically caused by blunt trauma to the orbit | *Typically caused by [[blunt eye trauma|blunt trauma]] to the orbit | ||
*Can result in permanent vision loss | *Can result in permanent [[vision loss]] | ||
**Outcome dependent on prevention of rebleeding and control of intraocular pressure | **Outcome dependent on prevention of rebleeding and control of intraocular pressure | ||
*In non-traumatic hyphema, all patients of African decent should be screened for [[sickle cell disease]] with hemoglobin electrophoresis | |||
[[File:Hyphema.jpeg|thumbnail|Hyphema, Grade II-III]] | |||
==Clinical Features== | ==Clinical Features== | ||
*Vision loss | *[[Vision loss]] | ||
* | *[[Eye pain]] | ||
*History of trauma to eye | *History of trauma to eye | ||
*Direct and consensual photophobia | *Direct and consensual photophobia | ||
*Nausea | *[[Nausea/vomiting]] | ||
*Hyphema grading | |||
**Grade I: ≤ 1/3 anterior chamber volume | |||
**Grade II: 1/3-1/2 anterior chamber volume | |||
**Grade III: > 1/2 anterior chamber volume | |||
**Grade IV: total anterior chamber volume, "eight ball hyphema" | |||
*Elevated grading correlates to increase in intraocular pressure<ref>Oldham GW. Hyphema. Jan 6, 2015. http://eyewiki.aao.org/Hyphema#Differential_diagnosis</ref> | |||
**13.5% have IOP increase in Grade I to II | |||
**52% with IOP increase in Grade IV | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Maxillofacial trauma DDX}} | |||
{{ | {{Unilateral red eye DDX}} | ||
===Spontaneous hyphema (non-traumatic hyphema)=== | |||
*[[Sickle cell disease]] | |||
*Ocular or laser surgery | |||
*[[HSV]], [[VZV]] [[uveitis]] | |||
*Neoplastic | |||
== | ==Evaluation== | ||
[[ | ''evaluation is best performed under [[slit-lamp exam]]'' | ||
*Blood in anterior chamber | *Blood in anterior chamber | ||
**May only see difference in color of irises if | **May only see difference in color of irises if patient is supine because blood layering is gravity dependent | ||
**Blood in anterior chamber only visible on slit lamp is a microhyphema | **Blood in anterior chamber only visible on slit lamp is a microhyphema | ||
*Vision loss | *[[Vision loss]] / Acuity changes | ||
*Inspect the lids, lashes, lacrimal ducts, and cornea | *Inspect the lids, lashes, lacrimal ducts, and cornea | ||
**Corneal abrasions often co-exist | **[[Corneal abrasions]] often co-exist | ||
*Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect | *Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect | ||
*Assess for [[Ruptured Globe]] which is associated with high energy mechanisms (shrapnel, BB guns, paintballs, etc) | |||
*Assess for [[Ruptured Globe]] | *Check intraocular pressure after [[Globe Rupture]] is excluded | ||
*Inquire about [[coagulopathy|bleeding diathesis]], [[anticoagulant]]/[[NSAID]]/[[aspirin]] use | |||
*Check intraocular pressure after [[Globe Rupture]] excluded | |||
*Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use | |||
== | ==Management== | ||
*Elevate head of bed | *Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs | ||
*Eye shield | *Eye shield | ||
*Pharmacologic control of pain and emesis | *Pharmacologic control of pain and emesis | ||
*Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants | |||
*If [[Glaucoma|IOP elevated]] (>22) the treatment is similar to [[glaucoma]] management except if there is also a concern for a [[retrobulbar hematoma]] as a result of trauma.<ref name="Brandt">Brandt, MT. Traumatic hyphema: a comprehensive review. Journal of oral and maxillofacial surgery. 2001; Vol. 59 Issue 12 Page 1462.</ref> Topical and oral treatments include | |||
**[[Acute angle-closure glaucoma#Management|Timolol]] | |||
**[[Acute angle-closure glaucoma#Management|Topical α-adrenergic agonist]] | |||
**[[Acute angle-closure glaucoma|Carbonic anhydrase inhibitors]] | |||
*Consult ophtho regarding: | *Consult ophtho regarding: | ||
**Dilation of pupil to avoid "pupillary play" | **Dilation of pupil to avoid '''"pupillary play"''' -constriction and dilation movements of the iris in response to changing lighting, which can stretch the involved iris vessel causing additional bleeding | ||
**Use of topical α-agonists and/or acetazolamide to decrease intraocular pressure | |||
*[[Cycloplegic]] can be given for comfort and to decease pupillary play if globe rupture has been excluded. Options include: | |||
**Use of topical | **[[Tropicamide]] (Mydriacyl) | ||
* | **[[Homatropine]] | ||
**[[Cyclopentolate]] (Cyclogyl, Cylate, Pentolair) | |||
**[[Scopolamine]] | |||
*Topical steroid | *[[Topical steroid]] | ||
*Treat any underlying coagulopathy | *Treat any underlying coagulopathy | ||
==Disposition== | ==Disposition== | ||
*Should be made by the ophthalmologist after examining the | *Should be made by the ophthalmologist after examining the patient | ||
**Hyphemas <33% of | **Hyphemas <33% of anterior chamber are frequently managed as outpatients | ||
*Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hyphema due to the association with [[sickle cell disease]] and [[hemophilia]] | |||
*Patients on anticoagulation or antiplatelet agents should be admitted for reversal and observation.<ref name="Brandt" /> | |||
===Discharge instructions=== | |||
*No reading (accommodation may further stress injured blood vessels) | |||
*Avoid NSAIDs | |||
*Wear hard shield at all times | |||
*Return to ED if rapid increase in size of hyphema or large increase in pain | |||
==Prognosis== | ==Prognosis== | ||
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**Complicates ~30% of cases | **Complicates ~30% of cases | ||
**Populations at highest risk: | **Populations at highest risk: | ||
***[[Sickle | ***[[Sickle cell disease]] or sickle cell trait | ||
***Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use) | ***Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use) | ||
***Initial intraocular pressure >22 mmHg | ***Initial intraocular pressure >22 mmHg | ||
Line 95: | Line 118: | ||
==References== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Ophthalmology]] |
Revision as of 22:48, 18 March 2020
Background
- Grossly visible blood in the anterior chamber of the eye
- Typically caused by blunt trauma to the orbit
- Can result in permanent vision loss
- Outcome dependent on prevention of rebleeding and control of intraocular pressure
- In non-traumatic hyphema, all patients of African decent should be screened for sickle cell disease with hemoglobin electrophoresis
Clinical Features
- Vision loss
- Eye pain
- History of trauma to eye
- Direct and consensual photophobia
- Nausea/vomiting
- Hyphema grading
- Grade I: ≤ 1/3 anterior chamber volume
- Grade II: 1/3-1/2 anterior chamber volume
- Grade III: > 1/2 anterior chamber volume
- Grade IV: total anterior chamber volume, "eight ball hyphema"
- Elevated grading correlates to increase in intraocular pressure[1]
- 13.5% have IOP increase in Grade I to II
- 52% with IOP increase in Grade IV
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Hemorrhagic chemosis
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Spontaneous hyphema (non-traumatic hyphema)
- Sickle cell disease
- Ocular or laser surgery
- HSV, VZV uveitis
- Neoplastic
Evaluation
evaluation is best performed under slit-lamp exam
- Blood in anterior chamber
- May only see difference in color of irises if patient is supine because blood layering is gravity dependent
- Blood in anterior chamber only visible on slit lamp is a microhyphema
- Vision loss / Acuity changes
- Inspect the lids, lashes, lacrimal ducts, and cornea
- Corneal abrasions often co-exist
- Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect
- Assess for Ruptured Globe which is associated with high energy mechanisms (shrapnel, BB guns, paintballs, etc)
- Check intraocular pressure after Globe Rupture is excluded
- Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use
Management
- Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs
- Eye shield
- Pharmacologic control of pain and emesis
- Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants
- If IOP elevated (>22) the treatment is similar to glaucoma management except if there is also a concern for a retrobulbar hematoma as a result of trauma.[2] Topical and oral treatments include
- Consult ophtho regarding:
- Dilation of pupil to avoid "pupillary play" -constriction and dilation movements of the iris in response to changing lighting, which can stretch the involved iris vessel causing additional bleeding
- Use of topical α-agonists and/or acetazolamide to decrease intraocular pressure
- Cycloplegic can be given for comfort and to decease pupillary play if globe rupture has been excluded. Options include:
- Tropicamide (Mydriacyl)
- Homatropine
- Cyclopentolate (Cyclogyl, Cylate, Pentolair)
- Scopolamine
- Topical steroid
- Treat any underlying coagulopathy
Disposition
- Should be made by the ophthalmologist after examining the patient
- Hyphemas <33% of anterior chamber are frequently managed as outpatients
- Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hyphema due to the association with sickle cell disease and hemophilia
- Patients on anticoagulation or antiplatelet agents should be admitted for reversal and observation.[2]
Discharge instructions
- No reading (accommodation may further stress injured blood vessels)
- Avoid NSAIDs
- Wear hard shield at all times
- Return to ED if rapid increase in size of hyphema or large increase in pain
Prognosis
- Rebleeding worsens prognosis as patients are at higher risk of permanent vision loss.
- Occurs 3-5 days after initial incident
- Complicates ~30% of cases
- Populations at highest risk:
- Sickle cell disease or sickle cell trait
- Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
- Initial intraocular pressure >22 mmHg
- Pediatric patients
Grade | Anterior Chamber Filling | Normal Vision Prognosis |
I | <33% | 90% |
II | 33-50% | 70% |
III | >50% | 50% |
IV | 100% | 50% |
See Also
Video
{{#widget:YouTube|id=vQG9kL7mpyA}}
References
- ↑ Oldham GW. Hyphema. Jan 6, 2015. http://eyewiki.aao.org/Hyphema#Differential_diagnosis
- ↑ 2.0 2.1 Brandt, MT. Traumatic hyphema: a comprehensive review. Journal of oral and maxillofacial surgery. 2001; Vol. 59 Issue 12 Page 1462.