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Emergency And Acute Medicine: Hyphema
Basics
Description Blood in the anterior chamber of the eye between the iris and cornea. Hyphema refers to grossly visible layered blood. Microhyphema refers to suspended red blood cells seen only on slit-lamp exam. Genetic predisposition is related to hereditary blood dyscrasias.
Etiology Blunt trauma is the most common cause (70–80%) due to anteroposterior compression with equatorial globe expansion causing rupture of iris or ciliary body vessels. Penetrating trauma causes direct vessel injury or sudden ocular decompression. Spontaneous causes include ocular tumors (melanoma, retinoblastoma, xanthogranuloma, metastatic tumors), blood dyscrasias (hemophilia, leukemia, thrombocytopenia, von Willebrand disease), anticoagulant or antiplatelet use (aspirin, warfarin, heparin), iris neovascularization (proliferative diabetic retinopathy, retinal vein occlusion, carotid stenosis), and postsurgical causes such as cataract extraction, trabeculectomy, or vitrectomy. In children without trauma, suspect nonaccidental injury.
Diagnosis
Signs And Symptoms Photophobia, blurred vision, decreased visual acuity, ocular pain, nausea, and vomiting.
History Assess prior visual acuity, prior ocular surgery or glaucoma treatment, bleeding disorders including sickle cell disease, mechanism and timing of injury, onset of visual loss, and history of excessive tearing (suggestive of open globe injury).
Physical Exam Perform full trauma exam. Look for periorbital ecchymosis, eyelid lacerations, enophthalmos, limited ocular movement with diplopia, or proptosis. Ocular exam includes visual acuity, exclusion of open globe injury before tonometry, pupillary response, slit-lamp exam, and dilated fundus exam without pressure on the globe. Hyphema grading: Grade I <1/3 AC, Grade II 1/3–1/2 AC, Grade III >1/2 AC, Grade IV total (“8-ball” hyphema). Higher grades have increased risk of rebleeding, glaucoma, corneal staining, and poor visual recovery.
Diagnosis Tests And Interpretation
Lab Obtain platelet count, PT/PTT if bleeding disorder or anticoagulant use is suspected. Screen for sickle cell disease when indicated.
Imaging CT orbits for suspected open globe, intraocular foreign body, or orbital fracture. B-scan ultrasound only if globe integrity is confirmed and posterior structures cannot be visualized.
Essential Workup Visual acuity, globe integrity, intraocular pressure, assessment for associated injuries, targeted labs, and imaging when indicated.
Differential Diagnosis Uveitis, endophthalmitis.
Treatment
Prehospital Place eye shield if open globe is suspected.
Initial Stabilization/Therapy Keep head elevated, limit activity, avoid straining, place rigid eye shield, and avoid eye patching.
Emergency Department Treatment/Procedures Provide mild analgesia (avoid NSAIDs) and antiemetics. Use cycloplegics (atropine 1% or cyclopentolate 1%) and topical steroids (prednisolone acetate 1%). Aminocaproic acid may be used in consultation with ophthalmology. Oral prednisone may be indicated in selected high-risk cases. Manage elevated intraocular pressure with topical beta-blockers first, then alpha-agonists, carbonic anhydrase inhibitors, and systemic agents if needed. Avoid carbonic anhydrase inhibitors and mannitol in sickle cell disease. Surgical evacuation is indicated for uncontrolled intraocular pressure.
Medications
First Line Atropine 1% TID, prednisolone acetate 1% QID.
Second Line Timolol or levobunolol, brimonidine or apraclonidine, dorzolamide or brinzolamide, acetazolamide.
Follow-Up And Disposition
Admission Criteria Uncontrolled intraocular pressure, open globe injury, noncompliance, associated injuries, children <7 years, or high-risk conditions such as sickle cell disease or hemophilia.
Discharge Criteria Controlled intraocular pressure and absence of admission criteria.
Follow-Up Recommendations Daily ophthalmology follow-up for the first 3 days to monitor for rebleeding, corneal staining, and pressure elevation.
Pearls And Pitfalls Always exclude ruptured globe before tonometry or treatment. Intraocular pressure reduction is not immediate. Screen for sickle cell disease in at-risk populations.
Basics
Description Blood in the anterior chamber of the eye between the iris and cornea. Hyphema refers to grossly visible layered blood. Microhyphema refers to suspended red blood cells seen only on slit-lamp exam. Genetic predisposition is related to hereditary blood dyscrasias.
Etiology Blunt trauma is the most common cause (70–80%) due to anteroposterior compression with equatorial globe expansion causing rupture of iris or ciliary body vessels. Penetrating trauma causes direct vessel injury or sudden ocular decompression. Spontaneous causes include ocular tumors (melanoma, retinoblastoma, xanthogranuloma, metastatic tumors), blood dyscrasias (hemophilia, leukemia, thrombocytopenia, von Willebrand disease), anticoagulant or antiplatelet use (aspirin, warfarin, heparin), iris neovascularization (proliferative diabetic retinopathy, retinal vein occlusion, carotid stenosis), and postsurgical causes such as cataract extraction, trabeculectomy, or vitrectomy. In children without trauma, suspect nonaccidental injury.
Diagnosis
Signs And Symptoms Photophobia, blurred vision, decreased visual acuity, ocular pain, nausea, and vomiting.
History Assess prior visual acuity, prior ocular surgery or glaucoma treatment, bleeding disorders including sickle cell disease, mechanism and timing of injury, onset of visual loss, and history of excessive tearing (suggestive of open globe injury).
Physical Exam Perform full trauma exam. Look for periorbital ecchymosis, eyelid lacerations, enophthalmos, limited ocular movement with diplopia, or proptosis. Ocular exam includes visual acuity, exclusion of open globe injury before tonometry, pupillary response, slit-lamp exam, and dilated fundus exam without pressure on the globe. Hyphema grading: Grade I <1/3 AC, Grade II 1/3–1/2 AC, Grade III >1/2 AC, Grade IV total (“8-ball” hyphema). Higher grades have increased risk of rebleeding, glaucoma, corneal staining, and poor visual recovery.
Diagnosis Tests And Interpretation
Lab Obtain platelet count, PT/PTT if bleeding disorder or anticoagulant use is suspected. Screen for sickle cell disease when indicated.
Imaging CT orbits for suspected open globe, intraocular foreign body, or orbital fracture. B-scan ultrasound only if globe integrity is confirmed and posterior structures cannot be visualized.
Essential Workup Visual acuity, globe integrity, intraocular pressure, assessment for associated injuries, targeted labs, and imaging when indicated.
Differential Diagnosis Uveitis, endophthalmitis.
Treatment
Prehospital Place eye shield if open globe is suspected.
Initial Stabilization/Therapy Keep head elevated, limit activity, avoid straining, place rigid eye shield, and avoid eye patching.
Emergency Department Treatment/Procedures Provide mild analgesia (avoid NSAIDs) and antiemetics. Use cycloplegics (atropine 1% or cyclopentolate 1%) and topical steroids (prednisolone acetate 1%). Aminocaproic acid may be used in consultation with ophthalmology. Oral prednisone may be indicated in selected high-risk cases. Manage elevated intraocular pressure with topical beta-blockers first, then alpha-agonists, carbonic anhydrase inhibitors, and systemic agents if needed. Avoid carbonic anhydrase inhibitors and mannitol in sickle cell disease. Surgical evacuation is indicated for uncontrolled intraocular pressure.
Medications
First Line Atropine 1% TID, prednisolone acetate 1% QID.
Second Line Timolol or levobunolol, brimonidine or apraclonidine, dorzolamide or brinzolamide, acetazolamide.
Follow-Up And Disposition
Admission Criteria Uncontrolled intraocular pressure, open globe injury, noncompliance, associated injuries, children <7 years, or high-risk conditions such as sickle cell disease or hemophilia.
Discharge Criteria Controlled intraocular pressure and absence of admission criteria.
Follow-Up Recommendations Daily ophthalmology follow-up for the first 3 days to monitor for rebleeding, corneal staining, and pressure elevation.
Pearls And Pitfalls Always exclude ruptured globe before tonometry or treatment. Intraocular pressure reduction is not immediate. Screen for sickle cell disease in at-risk populations.
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