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

Hyphema, Grade II-III
  • 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

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
  • 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