Traumatic hyphema

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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 Black patients 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 and Vomiting
  • Hyphema grading correlates to IOP increase[1]
    • Grade 0 to IV
    • 13.5% have IOP increase in Grade I to II
    • 52% with IOP increase in Grade IV

Differential Diagnosis

Maxillofacial Trauma

Orbital trauma

Acute

Subacute/Delayed

Unilateral Red Eye

^Emergent diagnoses

^^Critical diagnoses

Spontaneous hyphema (non-traumatic hyphema)

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, paint balls, etc)
  • Check intraocular pressure after Globe Rupture is excluded
  • Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use

Managment

  • 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:
  • 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 hypthemas due to the association with sickle cell disease and hemophilia
  • Patients on anticoagulation or anti-platelets 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

References

  1. Oldham GW. Hyphema. Jan 6, 2015. http://eyewiki.aao.org/Hyphema#Differential_diagnosis
  2. 2.0 2.1 Brandt, MT. Traumatic hyphema: a comprehensive review. Journal of oral and maxillofacial surgery. 2001; Vol. 59 Issue 12 Page 1462.