Author:
Sami H.Uwaydat
Jamil D.Bayram
Description
- Blood in anterior chamber (AC) of the eye (between iris and cornea)
- Hyphema: Grossly visible layering of blood
- Microhyphema: Suspended RBCs visible by slit lamp only
- Genetics:
- Genetic predisposition is related to hereditary blood dyscrasias (see below)
Etiology
- Blunt trauma: Most common (70-80%)
- Anteroposterior compression of the globe with simultaneous equatorial globe expansion causing rupture of iris stromal/ciliary body vessels
- Penetrating trauma: Direct injury to stromal vessels or sudden ocular decompression
- Spontaneous: Less common, lower incidence of complications:
- Tumors:
- Melanoma
- Retinoblastoma
- Xanthogranuloma
- Metastatic tumors
- Blood dyscrasias:
- Hemophilia
- Leukemia
- Thrombocytopenia
- von Willebrand disease
- Blood thinners: Aspirin, Coumadin, heparin, Pradaxa
- Neovascularization of iris: In proliferative diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, carotid stenosis
- Postsurgical: Cataract extraction, trabeculectomy, pars plana vitrectomy
ALERT |
| In children with no clear history of trauma, suspect child abuse |
Signs and Symptoms
- Photophobia
- Blurring of vision
- Decreased visual acuity
- Ocular pain
- Nausea/vomiting
History
- Previous visual acuity
- Prior eye surgery
- Prior glaucoma treatment
- Past medical history (blood disorders including sickle cell disease)
- Mechanism of trauma
- Exact time of injury and of visual loss
- History of excessive tearing after injury
ALERT |
| History of excessive tearing may indicate open globe injury |
Physical Exam
- General physical exam with emphasis on associated bodily injuries
- Periorbital ecchymosis
- Eyelid lacerations
- Enophthalmos (depression of the globe within the orbit)
- Limited ocular movement with diplopia (may indicate orbital floor fracture)
- Proptosis (may indicate retro-orbital hemorrhage)
- Ocular exam:
- Visual acuity
- Rule out open globe (positive Seidel sign, corneal laceration, diffuse subconjunctival hemorrhage, decreased ocular motility, prolapse of intra-ocular structures)
- Pupillary reaction to light (check for afferent pupillary defect prior to using dilating drops)
- Tonometry for intraocular pressure (IOP) measurement
ALERT |
- Exclude globe perforation before measuring IOP; low pressure can indicate globe perforation
- Slit-lamp exam; look for layer of blood in AC:
- Four grades of hyphema depending on percentage of AC occlusion by blood:
- Grade I: <1/3
- Grade II: 1/3-1/2
- Grade III: >1/2
- Grade IV: Total (called 8-ball hyphema; blood is dark and filling 100% of AC)
- High-grade hyphemas are:
- More likely to rebleed (25% of grade I compared with 67% of grade III)
- More likely to develop glaucoma and corneal staining
- Less likely to recover visual acuity
- Dilated fundus exam (avoid pressure on globe)
|
Diagnostic Tests & Interpretation
Lab
- Lab tests should be individualized depending on the case
- Platelet count, PT/PTT, bleeding time if bleeding disorder is suspected, or if the patient is on anticoagulants
- BUN, creatinine, and pregnancy test if aminocaproic acid is to be used (see below)
- Factor VIII assay if family history of hemophilia
- Sickle cell screen especially in African Americans and Mediterranean descent
Imaging
- CT orbits (1-mm cuts) if open globe injury, intraocular foreign body, or orbital wall fracture are suspected
- US biomicroscopy (B scan) if total hyphema and intraocular structures cannot be visualized
ALERT |
| Do not perform B scan if open globe injury is suspected (pressure applied during this procedure may cause extrusion of intraocular contents) |
Essential Workup
- Exam: Visual acuity, status of globe, IOP, associated ocular/bodily injuries
- Labs: Platelet count, Pt/PTT, and sickle cell screen if indicated
- Imaging: B scan or CT orbits if indicated
Differential Diagnosis
Prehospital
Place eye shield in case of suspected corneal perforation
Initial Stabilization/Therapy
- Keep head upright to allow blood in AC to settle down
- Limit activity; avoid bending, straining, or exertion
- Place metal or plastic shield over involved eye until integrity of globe is confirmed
- Do not patch affected eye (if eye is patched, patient cannot notice sudden loss of vision)
- Note that metal and plastic shields have holes that let patient see through whereas patch completely blocks patient's vision
ED Treatment/Procedures
- Evidence to show a significant effect on visual acuity by medical interventions is limited
- Mild analgesics (avoid nonsteroidal anti-inflammatory drugs [NSAIDs] because of antiplatelet effect)
- Antiemetics (associated N/V may worsen hyphema by increasing IOP)
- Cycloplegics decrease pain from iritis:
- Atropine 1% eye drops 2-3 times per day until hyphema resolves
- Topical steroids may decrease inflammation from iritis:
- Prednisolone acetate 1% eye drops (or equivalent) 4-8 times per day until hyphema resolves (usually 7-10 d)
- Aminocaproic acid (antifibrinolytic):
- Use in consultation with ophthalmologist:
- Not commonly used because of frequent systemic side effects
- Stabilizes fibrin clot in AC and decreases incidence of rebleed, but has no effect on final visual outcome
- 50 mg/kg PO q4h for total of 5 d (do not exceed 30 g/d). Dose should be adjusted in renal failure
- May cause postural hypotension, nausea, vomiting, diarrhea
- New topical form is not yet FDA approved
- Do not use in pregnant women or in patients prone to thrombosis. It can also cause acute renal failure in patients with hemophilia
- Prednisone:
- Indications:
- Hemophilia
- Uncooperative children
- Total hyphema
- History of thrombotic disease
- Dose: 0.6-0.75 mg/kg/24 hr in div doses, up to 60 mg/d for 5 d
- For increased IOP:
- For non-sickle cell patients, treat if IOP >30 mm Hg
- For sickle cell patients, treat if IOP >24 mm Hg
- Treat until IOP is controlled as indicated above
- Always start with one medication. Add another if unsuccessful in controlling pressure:
- B-blockers - drug of choice: Timolol or levobunolol 0.5% b.i.d
- α-agonist: Brimonidine 0.2% or apraclonidine 0.5% t.i.d
- Topical carbonic anhydrase inhibitors (CAI): Dorzolamide 2% or brinzolamide 1% t.i.d
- Oral CAI: Acetazolamide 500 mg PO q12h (peds: 8-30 mg/kg/24 hr q6-8h) or methazolamide 50 mg q8h
- Mannitol (1-2 mg/kg IV over 45 min q24h) when all other eye drops fail to lower IOP to acceptable level
- Avoid CAI and mannitol in sickle cell patients, as they may cause acidosis and induce sickling
- Allow 25-30 min for each eye drop to work. If after using all the drops and mannitol, IOP is still high, then surgical evacuation of blood clot is warranted (AC tap or washout)
- Drugs to avoid:
- Pilocarpine: Constricts pupil and prevents visualization of lens and retina
- Prostagland in eye drops (e.g., latanoprost): Increase inflammatory response
ALERT |
- ∼5% of patients with traumatic hyphema require surgery
- Criteria for immediate consultation with ophthalmologist from the ED (if possible, consultation should be arranged within 24 hr):
- Visual acuity worse than 20/200 at presentation
- Sickle cell disease/trait with high IOP
- Large hyphema (filling >1/3 of AC)
- Medically uncontrolled IOP
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Medication
First Line
- Atropine 1% t.i.d:
- Prednisolone acetate 1% q.i.d
Second Line
- Timolol 0.5% or levobunolol 0.5% b.i.d
- Brimonidine 0.2% or apraclonidine 0.5% t.i.d
- Dorzolamide 2% or brinzolamide 1% t.i.d
- Acetazolamide 500 mg PO q12h
Disposition
- Discharge patient on atropine, prednisolone, and any appropriate IOP-lowering medications
- Continue aminocaproic acid if decision was made to start it in ED
- Anti-emetics if needed
- Stool softeners to minimize straining during bowel movements
Admission Criteria
- Hyphema size is not a criterion for discharge or admission; IOP control is the most important
- Medically uncontrolled IOP requiring surgical intervention
- Ruptured globe
- Noncompliant patients
- Associated ocular or orbital injuries
- Children <7 yr of age:
- Age group is usually at risk of amblyopia (also called lazy eye, which is irreversible visual loss secondary to visual deprivation in early childhood)
- Patients at risk of complications (sickle cell disease, hemophilia)
Discharge Criteria
Absence of any admission criteria with IOP <30 mm Hg for non-sickle patients and <24 mm Hg for patients with sickle cell disease/trait
Follow-up Recommendations
- Arrange for follow-up with ophthalmologist:
- Daily slit-lamp exam daily for 3 d after initial trauma, to monitor for rebleeding, corneal staining, and increased IOP
- Follow-up exam will determine length of treatment with atropine, prednisone acetate, and IOP-lowering eye drops
- BerkeS. Post-traumatic glaucoma. In: YanoffM, DukerJ, eds. Ophthalmology. 2nd ed.St. Louis, MO: Mosby; 2004:1518-1521.
- CrouchER Jr, CrouchER. Management of traumatic hyphema: Therapeutic options . J Pediatr Ophthalmol Strabismus. 1999;35(5):238-250; quiz 279-280.
- CulomRD Jr, ChangB, eds. Hyphema and microhyphema. In: RheeDJ, PyferMF, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 3rd ed.Philadelphia, PA: Lippincott Williams & Wilkins; 1999:32-37.
- GharaibehA, SavageHI, SchererRW, et al. Medical interventions for traumatic hyphema . Cochrane Database Syst Rev. 2013;(12):CD005431.
- HamillMB. Current concepts in the treatment of traumatic injury to the anterior segment . Ophthalmol Clin North Am. 1999;12(3):457-464.
- KarkhanehR, NaeeniM, ChamsH, et al. Topical aminocaproic acid to prevent rebleeding in cases of traumatic hyphema . Eur J Ophthalmol. 2003;13(1):57-61.
- PieramiciDJ, GoldbergMF, MeliaM, et al. A phase III, multicenter, rand omized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema . Ophthalmology. 2003;110(11):2106-2112.
- SankarPS, ChenTC, GrosskrentzCL, et al. Traumatic hyphema . Int Ophthalmol Clin. 2002;42(3):57-68.
- WaltonW, Von HagenS, GrigorianR, et al. Management of traumatic hyphema . Surv Ophthalmol. 2002;47(4):297-334.
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