Traumatic hyphema

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

Hyphema, Grade II-III

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
  • 13.5% have IOP increase in Grade I to II
  • 52% with IOP increase in Grade IV

Differential Diagnosis

Maxillofacial Trauma

• Ears
  • Auricular hematoma
• Nose
  • Nasal fracture
  • Nasal septal hematoma
• Oral
  • Dental trauma
  • Lip laceration
  • Tongue laceration
• Other face
  • Le Fort fractures
  • Mandible fracture
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Related
  • Head trauma (main)
    • Skull fracture
    • Skull fracture (peds)
    • Basilar skull fracture
  • Orbital trauma
    • Eyelid laceration
  • Scalp laceration

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
    • Ocular compartment syndrome
  • 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. Topical and oral treatments include
  • Timolol
  • Topical α-adrenergic agonist
  • Carbonic anhydrase inhibitors
• 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 (avoid acetazolamide if the patient has sickle cell disease as this increase sickling)
• 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.

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

• Blunt orbital trauma