Hyphema

Aka: Hyphema, Anterior Chamber Hemorrhage, Traumatic Hyphema

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II. Definitions

  1. Hyphema
    1. Bleeding in the anterior chamber of the eye

III. Causes

  1. Blunt Eye Injury (most common)
    1. Injury to the iris root (outer edge of the iris where it meets the Sclera)
    2. Subsequent bleeding arises from the iris blood vessels
  2. Post-surgical
  3. Spontaneous bleeding without injury history
    1. Leukemia
    2. Lymphoma
    3. Child Abuse

IV. Symptoms

  1. Eye Pain
  2. Blurred Vision

V. Exam

  1. Evaluate for other Eye Trauma as well as other facial Trauma, Closed Head Injury
  2. Blood layers as in a pool in the inferior aspect of the anterior chamber
  3. Determine amount of bleeding (height of Hyphema)
    1. Total Hyphema (8 ball Hyphema) completely obscures pupil
  4. Microscopic Hyphema may be subtle
    1. Red Blood Cells in anterior chamber may only be seen floating on Slit Lamp exam
  5. Evaluate for Globe Rupture
  6. Intraocular Pressure
    1. High pressure suggests blood clogging the trabecular drainage
  7. Eye Pain with Pupil Constriction

VI. Grading

  1. Grade 1: Anterior chamber filled<33% with blood
  2. Grade 2 Anterior chamber filled 33 to 50% with blood
  3. Grade 3 Anterior chamber filled >50% with blood
  4. Grade 4 Anterior chamber filled almost completely or completely with blood (8 ball)

VII. Labs

  1. Sickle Cell preparation in non-caucasian patients
    1. Perform even in Traumatic cases (this is emphasized by ophthalmologists)
    2. Significantly worse outcomes (even for Sickle Cell Trait)

VIII. Management

  1. Restrict movement
    1. Bed rest with head of bed at 30 degrees
    2. No reading
    3. Avoid pressure on eye (risks dislodged clot and rebleeding)
  2. Symptomatic Management
    1. Analgesics
    2. Antiemetics
  3. Fox metal shield (or small paper cup) to cover injured eye
    1. Prevents further Eye Injury
  4. Urgent Referral to Ophthalmology Indications
    1. Grade 3-4 Hyphema
    2. Bleeding Disorders (see below)
    3. Increased Intraocular Pressure
    4. Early Corneal blood staining
    5. Decreased Visual Acuity
    6. Active bleeding
  5. Inpatient management indications
    1. Systemic aminocaproic acid (AMICAR)
    2. Secondary Hemorrhage
    3. Suspected Nonaccidental Trauma
    4. Hyphema >50%
    5. Sickle Cell Anemia or Sickle Cell Trait
    6. Unreliable follow-up
  6. Outpatient management
    1. Topical Corticosteroids
      1. Consider in Consultation with ophthalmology
    2. Atropine 1% single dose
      1. Results in complete paralysis of the iris Muscle for 2 weeks
      2. Other Cycloplegics do not completely paralyze the iris and require frequent re-dosing
    3. Glaucoma agent (if Intraocular Pressure increased)
      1. Intraocular Beta Blocker (e.g. Timolol) - Preferred first-line agent
      2. Intraocular Carbonic Anhydrase Inhibitor (Trusopt, Azopt)
      3. Intraocular Alpha-2 Adrenergic Agonist (Lopidine, Alphagan)

IX. Management: Bleeding Disorder (esp. Sickle Cell Anemia)

  1. Indications
    1. Sickle Cell Disease or Sickle Cell Trait
    2. Hemophilia
    3. Von Willebrand Disease
  2. Requires emergent management
    1. Risk of Eye vaso-Occlusion
    2. Risk of acute angle closure Glaucoma
    3. Risk of Vision Loss
  3. Admit all Sickle Cell Anemia patients with Hyphema (even small Hyphemas)
  4. Raise head of bed
  5. Consult ophthalmology
  6. Agents that may be used in Sickle Cell Disease and Hyphema
    1. Beta Blockers
    2. Clonidine
  7. Avoid medications in Sickle Cell Disease that cause sickling
    1. Acetazolamide (Diamox)
    2. Diuretics
    3. Mannitol
    4. Topical beta Agonists (e.g. Epinephrine)

X. Complications

  1. Blindness
    1. Results from Hyphema rebleeding (from dislodged clot)
  2. Corneal blood staining
  3. Glaucoma
  4. Retinal Injury

XI. Prognosis

  1. Small Hyphemas tend to heal well without complication
  2. Risk factors for complications and worse outcomes
    1. Sickle Cell Anemia (including Sickle Cell Trait)
    2. Large Hyphema
    3. Rebleeding

XII. References

  1. Majoewsky (2012) EM:Rap 12(1): 4
  2. Glassberg and Weingart in Majoewsky (2012) EM:Rap 12(9): 3-4
  3. Grzybowski and Ponce (2021) Crit Dec Emerg Med 34(7): 23

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