Traumatic hyphema
Revision as of 23:38, 28 April 2015 by Rossdonaldson1 (talk | contribs)
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
Clinical Features
- Vision loss
- Earliest symptom is decreased vision
- Eye pain
- History of trauma to eye
- Direct and consensual photophobia
- Nausea and Vomiting
Diagnosis
- Blood in anterior chamber
- May only see difference in color of irises if pt is supine because blood layering is gravity dependent
- Blood in anterior chamber only visible on slit lamp is a microhyphema
- Vision loss
Work-Up
- Visual Acuity
- 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
- Slit lamp
- Assess for Ruptured Globe
- Common with high energy mechanism (shrapnel, BB guns, paint balls, etc)
- Check intraocular pressure after Globe Rupture excluded
- Consider screening for sickle-cell
- Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Treatment
- Elevate head of bed
- Eye shield
- Pharmacologic control of pain and emesis
- Consult ophtho regarding:
- Dilation of pupil to avoid "pupillary play"
- Constriction and dilation movements of the iris in response to changing lighting
- Can stretch the involved iris vessel causing additional bleeding
- Use of topical alpha-agonists and/or acetazolamide to decrease intraocular pressure
- Dilation of pupil to avoid "pupillary play"
- No reading (accommodation may further stress injured blood vessels)
- Cycloplegic
- For comfort if globe rupture has been excluded
- Topical steroid
- Treat any underlying coagulopathy
Disposition
- Should be made by the ophthalmologist after examining the pt
- Hyphemas <33% of ant chamber are frequently managed as outpatients
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 Dz or sickle cell trait
- Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
- Initial intraocular pressure >22 mmHg
- Pediatric patients
Grade | Ant Chamber Filling |
Nl Vision Prognosis |
I | <33% | 90% |
II | 33-50% | 70% |
III | >50% | 50% |
IV | 100% | 50% |
See Also
Source
- UpToDate
- Tintinalli