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

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

DDx

• Ruptured Globe
• Retinal Detachment
• Rebleeding

Treatment

1. Elevate head of bed
2. Eye shield
3. Pharmacologic control of pain and emesis
4. Consult ophtho regarding:
   1. Dilation of pupil to avoid "pupillary play"
      1. Constriction and dilation movements of the iris in response to changing lighting
      2. Can stretch the involved iris vessel causing additional bleeding
   2. Use of topical alpha-agonists and/or acetazolamide to decrease intraocular pressure
5. No reading (accommodation may further stress injured blood vessels)
6. Cycloplegic
   1. For comfort if globe rupture has been excluded
7. Topical steroid
8. Treat any underlying coagulopathy

Disposition

1. Should be made by the ophthalmologist after examining the pt
   1. 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

• Ruptured Globe
• Retinal Detachment

Source

• UpToDate
• Tintinalli