Ophthalmology – Hyphema

Basics

Description

Hyphema is the presence of blood within the anterior chamber of the eye. The blood may appear as suspended red blood cells, a layered collection, or a clot.

Most cases follow ocular trauma, but hyphema may also occur after intraocular surgery, laser procedures, neovascularization, tumors, inflammation, or bleeding disorders.

Because a hyphema can be associated with other serious ocular injuries, the first priority is always to exclude open-globe injury and intraocular foreign body.

General Prevention

Prevention centers on the use of appropriate protective eyewear, especially during sports, occupational activities, and situations involving high-velocity objects.

Polycarbonate protective lenses are particularly useful for patients at increased risk of recurrent ocular trauma.

Pathophysiology

Hyphema results from bleeding from anterior-segment structures.

In traumatic cases, the mechanism commonly involves tearing of vessels in the:

• Iris
• Ciliary body
• Anterior chamber angle

Associated injuries may include:

• Iris sphincter tears
• Iridodialysis
• Cyclodialysis
• Angle recession

Blood then accumulates within the aqueous-filled anterior chamber.

Red blood cells can obstruct the trabecular meshwork and produce elevated intraocular pressure.

Etiology

The most common cause is blunt ocular trauma.

Other causes include:

• Penetrating trauma
• Intraocular surgery
• Laser procedures
• Iris or angle neovascularization
• Intraocular tumors
• Uveitis
• Coagulopathy
• Anticoagulant or antiplatelet therapy
• Hemoglobinopathies such as sickle cell disease

Commonly Associated Conditions

Hyphema may be associated with:

• Open-globe injury
• Lens dislocation
• Traumatic cataract
• Angle recession
• Iridodialysis
• Cyclodialysis
• Vitreous hemorrhage
• Retinal tears or detachment
• Choroidal rupture
• Traumatic optic neuropathy
• Coagulopathies
• Intraocular neoplasms
• Neovascular glaucoma

Diagnosis

History

When trauma is suspected, obtain a careful description of the mechanism.

Important details include:

• Type of object
• Size and shape
• Velocity
• Direction of impact
• Exact site of impact
• Use of protective eyewear
• Time since injury

A high-velocity projectile raises concern for an intraocular foreign body, while blunt trauma from a fist or ball may produce extensive angle and iris injury despite an intact globe.

Ask specifically about:

• Anticoagulant or antiplatelet medication
• Bleeding disorders
• Sickle cell disease or trait
• Previous ocular surgery
• Previous trauma
• Prior glaucoma

Physical Examination

The initial examination should first determine whether the globe is intact.

If open globe is suspected, avoid unnecessary manipulation or pressure on the eye.

When safe, establish baseline:

• Visual acuity
• Pupillary examination
• Intraocular pressure
• Slit-lamp examination
• Dilated fundus examination

On slit-lamp examination, blood may appear:

• Suspended diffusely in the anterior chamber
• Layered inferiorly
• Clotted
• As a nearly total or total hyphema

Grading

A practical clinical grading system is based on the proportion of the anterior chamber filled with blood.

Microhyphema: circulating red blood cells without a visible layered collection.

Grade I: less than one-third of the anterior chamber filled.

Grade II: one-third to one-half filled.

Grade III: more than one-half but less than total.

Grade IV: total hyphema.

A completely dark or black total hyphema may indicate prolonged blood stasis and is sometimes called an eight-ball hyphema.

Diagnostic Tests and Interpretation

Visual Acuity

Visual acuity should be documented at presentation and during follow-up.

Reduction in vision may result from the blood itself, corneal edema, lens injury, retinal injury, or optic nerve damage.

Intraocular Pressure

IOP must be monitored carefully.

Pressure can rise when red blood cells, inflammatory debris, or clotted blood obstruct the trabecular meshwork.

Pressure elevation may occur immediately or several days after the initial injury.

Measurement of Hyphema

The height or proportion of layered blood should be documented at each visit.

Serial measurement allows assessment of:

• Resolution
• Enlargement
• Rebleeding

Laboratory Testing

Laboratory investigations depend on the clinical situation.

Consider:

• CBC
• Platelet count
• Coagulation studies
• Hemoglobin electrophoresis when appropriate

Patients at risk for sickle cell disease or sickle cell trait require particular attention because even modest IOP elevation may be more dangerous to the optic nerve and certain pressure-lowering medications may promote sickling.

Imaging

CT

If orbital fracture or intraocular foreign body is suspected, CT of the orbits is generally the preferred initial imaging study.

MRI should not be performed until a metallic intraocular foreign body has been excluded.

Ultrasound

B-scan ultrasonography can evaluate the posterior segment when the fundus cannot be visualized.

However, it should be used with extreme caution or deferred if an open globe is suspected.

Ultrasound Biomicroscopy

UBM may be useful later to evaluate:

• Angle anatomy
• Cyclodialysis
• Ciliary body abnormalities
• Lens position

Differential Diagnosis

The main diagnostic task is usually to determine the cause and associated injuries rather than to distinguish hyphema from many mimics.

Conditions that may resemble or accompany hyphema include:

• Anterior chamber inflammatory cells
• Pigment dispersion
• Hypopyon
• Iris neovascularization
• Intraocular tumor
• Uveitis-glaucoma-hyphema syndrome

Treatment

Management aims to:

• Protect the eye
• Prevent rebleeding
• Control inflammation
• Control intraocular pressure
• Prevent corneal blood staining
• Detect associated ocular injuries

General Measures

The patient should wear a rigid protective eye shield.

The head should be elevated, generally about 30–45 degrees, including during sleep, so that blood settles inferiorly and the visual axis remains relatively clear.

Activity should be restricted.

Avoid:

• Heavy lifting
• Bending
• Strenuous exercise
• Contact sports
• Activities associated with Valsalva

A pressure patch should generally be avoided because the patient should be able to detect changes in vision and because pressure on a traumatized globe is undesirable.

Pain and Nausea Control

Acetaminophen is usually preferred for pain.

Avoid aspirin and NSAIDs when possible because of their antiplatelet effects and potential to increase rebleeding.

Nausea and vomiting should be treated promptly with antiemetics because vomiting increases venous pressure and may promote rebleeding.

Stool softeners may be useful if straining is anticipated.

Topical Corticosteroids

Topical corticosteroids such as prednisolone acetate 1% are often used to reduce traumatic anterior chamber inflammation.

Frequency depends on the severity of inflammation.

If a significant corneal epithelial defect or abrasion is present, corticosteroid use should be individualized because steroids can delay epithelial healing and increase infection risk.

Cycloplegic Therapy

Cycloplegic agents reduce ciliary spasm, pain, and iris movement.

Common options include:

• Atropine
• Homatropine
• Cyclopentolate

Cycloplegia may also reduce the risk of posterior synechiae when significant inflammation is present.

Intraocular Pressure Elevation

IOP management depends on:

• Magnitude of pressure elevation
• Duration
• Optic nerve status
• Presence of sickle cell disease or trait

Beta-Blockers

Topical beta-blockers are commonly used as first-line pressure-lowering agents when not systemically contraindicated.

Alpha-2 Agonists

Agents such as brimonidine may be used selectively, with attention to age and systemic side effects.

Carbonic Anhydrase Inhibitors

Topical or systemic carbonic anhydrase inhibitors may be useful in many patients.

However, particular caution is required in sickle cell disease or trait, because systemic acidosis and changes in aqueous chemistry may worsen sickling.

Prostaglandin Analogs

These are often avoided in the acute inflammatory phase because of concern for exacerbating inflammation.

Sickle Cell Disease and Trait

Sickle cell patients deserve special consideration.

Sickling of red blood cells within the relatively hypoxic and acidic anterior chamber can obstruct aqueous outflow and produce marked IOP elevation.

Optic nerve and retinal ischemia may occur at pressures that would be better tolerated by other patients.

Therefore:

• Lower IOP thresholds for intervention may be appropriate.
• Carbonic anhydrase inhibitors and hyperosmotic agents require careful selection.
• Hematology consultation may be helpful.
• Surgical evacuation may be considered earlier.

Rebleeding

One of the most important complications is secondary hemorrhage, typically occurring several days after the original injury as the initial clot retracts and damaged vessels reopen.

Rebleeding can produce:

• Larger hyphema
• Higher IOP
• Greater risk of corneal blood staining
• Worse visual outcome

Close follow-up during the first several days is therefore important.

Antifibrinolytic Therapy

Agents such as aminocaproic acid were historically used to reduce rebleeding.

They are used much less commonly today because of side effects and limited routine benefit, but may occasionally be considered in selected high-risk patients.

Corneal Blood Staining

Corneal blood staining is a serious complication in which hemoglobin and iron products from lysed red blood cells enter the corneal stroma.

Risk is increased by:

• Large or total hyphema
• Prolonged hyphema
• Elevated intraocular pressure
• Corneal endothelial dysfunction

Early staining may appear yellowish.

Persistent blood staining can take months or longer to clear and may permanently affect vision.

Surgery

Anterior chamber washout may be required when medical management is insufficient.

Potential indications include:

• Persistently uncontrolled IOP
• Total or near-total hyphema that does not clear
• Corneal blood staining or high risk of staining
• Persistent large hyphema
• Earlier intervention in selected patients with sickle cell disease or trait

The exact threshold depends on the patient’s age, IOP, optic nerve status, size and duration of the hyphema, and systemic risk factors.

Anterior Chamber Washout

Surgical evacuation is performed carefully using irrigation and aspiration techniques.

The goal is to remove blood while minimizing:

• Iris trauma
• Lens injury
• Further disruption of clot
• Rebleeding

Inpatient Considerations

Most uncomplicated hyphemas can be managed as outpatients if the patient can comply with restrictions and return promptly for follow-up.

Admission may be considered for:

• Poor compliance
• Children in whom activity restriction is difficult
• Severe hyphema
• Uncontrolled IOP
• Rebleeding
• Sickle cell disease
• Monocular patients
• Associated major ocular injuries

Initial Stabilization

The initial priorities are:

1. Exclude open globe and intraocular foreign body.
2. Document visual acuity and pupillary function.
3. Measure IOP only if globe integrity is secure.
4. Perform slit-lamp examination.
5. Examine the retina when safely possible.
6. Protect the eye with a shield.
7. Treat significant pressure elevation and inflammation.

Follow-Up

Patients require close observation until the hyphema resolves and IOP remains stable.

Early follow-up is especially important because the risk of rebleeding and pressure elevation is greatest during the first several days.

The examination should monitor:

• Visual acuity
• Hyphema size
• IOP
• Corneal clarity
• Rebleeding
• Anterior chamber inflammation

Gonioscopy

After the acute injury has resolved, gonioscopy should be performed to evaluate for angle recession.

Gonioscopy is generally delayed until the eye is stable so that manipulation does not provoke rebleeding.

Angle-Recession Glaucoma

Blunt trauma can split the ciliary body face and widen the anterior chamber angle.

This angle recession can predispose to glaucoma months, years, or even decades later.

Therefore, patients with significant traumatic hyphema require long-term IOP surveillance.

Patient Education

Patients should be instructed to:

• Keep the protective shield in place as directed
• Sleep with the head elevated
• Avoid strenuous activity
• Avoid aspirin and NSAIDs unless medically essential
• Take prescribed drops exactly as directed
• Return immediately for increased pain or decreased vision

Patients should understand that apparent improvement does not eliminate the risk of delayed rebleeding or pressure elevation.

Prognosis

Most uncomplicated traumatic hyphemas resolve with good visual recovery.

Prognosis depends largely on the presence of associated injuries rather than on the hyphema alone.

Poorer outcomes are associated with:

• Open-globe injury
• Retinal damage
• Optic nerve injury
• Recurrent bleeding
• Persistent elevated IOP
• Corneal blood staining
• Severe angle recession

Complications

Important complications include:

• Rebleeding
• Elevated intraocular pressure
• Secondary glaucoma
• Angle-recession glaucoma
• Peripheral anterior synechiae
• Posterior synechiae
• Corneal blood staining
• Optic nerve damage
• Amblyopia in children
• Permanent visual loss from associated ocular trauma

The most important long-term issue after a traumatic hyphema is the possibility of delayed angle-recession glaucoma, which is why periodic lifelong ophthalmic surveillance may be appropriate after significant injury.