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. General Measures
    1. Raise head of bed
    2. Consult ophthalmology
  4. Sickle Cell Anemia
    1. Admit all Sickle Cell Anemia AND Sickle Cell Trait patients with Hyphema (even small Hyphemas)
    2. Acute Narrow Angle Glaucoma risk (due to Aqueous Humor obstruction)
      1. If IOP >25 mmHg, start ophthalmic medications (e.g. Timolol, Pilocarpine)
        1. See Acute Angle-Closure Glaucoma for acute protocol
      2. Avoid Carbonic Anhydrase Inhibitors (e.g. Acetazolamide)
        1. May worsen Glaucoma via decreased Blood Pressure and ocular pH
    3. Agents that may be used in Sickle Cell Disease and Hyphema
      1. Beta Blockers
      2. Clonidine
    4. 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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Related Studies

Ontology: Hyphema (C0020581)

Definition (NCI) Hemorrhage within the anterior chamber of the eye; bloodshot.
Definition (NCI_FDA) Hemorrhage within the anterior chamber of the eye; bloodshot.
Definition (MSH) Bleeding in the anterior chamber of the eye.
Concepts Pathologic Function (T046)
MSH D006988
ICD10 H21.0 , H21.00
SnomedCT 193502002, 267720002, 75229002
LNC LA17283-5
English Hyphemas, HAEMORRHAGE ANT CHAMBER EYE, HEMORRHAGE ANT CHAMBER EYE, Hyphema, Hemorrhage ant chamber eye, Haemorrhage ant chamber eye, hyphema (diagnosis), hyphema (physical finding), hyphema, anterior chamber hyphema, Anterior eye chamber haemorrhage, Anterior eye chamber hemorrhage, Hemorrhage of anterior chamber of eye, Hyphema, unspecified eye, Hyphema [Disease/Finding], hyphaemia, blood in anterior chamber, hyphemia, Haemorrhage of anterior chamber of eye, Hyphaema (disorder), HYPHEMA, Hyphemia, Blood in anterior chamber, Hyphaema, Hyphaemia, Hyphema (disorder), eye; hemorrhage, anterior chamber, hemorrhage; eye, anterior chamber, hyphaema
French HYPHEMA, Hémorragie de la chambre antérieure de l'oeil, Hyphème, HEMORRAGIE CHAMBRE ANTER OEIL, Hyphéma, Hémorragie dans la chambre antérieure de l'oeil
Portuguese HIFEMA, Hemorragia da câmara anterior do olho, HEMORRAGIA DA CAMARA ANT DO OLHO, Hifema
Spanish HIPEMA, Hemorragia de la cámara anterior del ojo, HEMORRAGIA CAMARA ANTERIOR OJO, hifema (trastorno), hifema, sangre en cámara anterior, Hifema, Hipema
Dutch hemorragie voorste oogkamer, hemorragie van voorste oogkamer, bloeding van voorste oogkamer, bloeding; oog, voorste oogkamer, oog; bloeding, voorste oogkamer, hyphaema, Bloeding; corpus; ciliare, Bloeding; voorste oogkamer, Hyphaema
German Vorderaugenkammer, Blutung, Blutung der vorderen Kammer des Auges, Blutung, Vordkamm Auge, BLUTUNG AUGENVORDERKAMMER, HYPHEM, Hyphaema
Italian Emorragia della camera anteriore dell'occhio, Ifema
Japanese 前房出血, ｾﾞﾝﾎﾞｳｼｭｯｹﾂ
Swedish Hyphema
Czech krvácení do přední komory oční, hyphéma, Krvácení do přední komory oční, Hemoragie přední komory oční, Hyphema
Finnish Hyfeema
Russian GIFEMA, ГИФЕМА
Korean 전방출혈
Croatian HIFEMA
Polish Krwiak komory przedniej
Hungarian Elülső szemcsarnok vérzés, Elülső szemcsarnok vérzése, Hyphaema, Hyphema
Norwegian Hyfema
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Traumatic hyphema (C0339335)

Concepts Injury or Poisoning (T037)
ICD10 S05.1
SnomedCT 231954005
English traumatic hyphema (diagnosis), traumatic hyphema, Traumatic hyphaema, Traumatic hyphema, Traumatic hyphema (disorder), hyphema; traumatic, traumatic; hyphema
Dutch hyphaema; traumatisch, traumatisch; hyphaema
Spanish hipema traumático (trastorno), hipema traumático
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Traumatic Injury

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