Hyphema, Anterior Chamber Hemorrhage

  • Definitions
  1. Hyphema
    1. Bleeding in the anterior chamber of the eye
  • 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
  • Exam
  1. Blood layers as in a pool in the inferior aspect of the anterior chamber
  2. Determine amount of bleeding (height of Hyphema)
    1. Total Hyphema (8 ball Hyphema) completely obscures pupil
  3. Microscopic Hyphema may be subtle
    1. Red Blood Cells in anterior chamber may only be seen floating on Slit Lamp exam
  4. Evaluate for Globe Rupture
  5. Intraocular Pressure
    1. High pressure suggests blood clogging the trabecular drainage
  • 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)
  • 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. Fox metal shield (or small paper cup) to cover injured eye
    1. Prevents further Eye Injury
  3. Immediate Referral to Ophthalmology
  4. Consider inpatient management
    1. Systemic aminocaproic acid (AMICAR)
  5. 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)
  1. Requires emergent management
    1. Risk of Eye vaso-Occlusion
    2. Risk of acute angle closure Glaucoma
    3. Risk of Vision Loss
  2. Admit all Sickle Cell Anemia patients with Hyphema (even small Hyphemas)
  3. Raise head of bed
  4. Consult ophthalmology
  5. Agents that may be used in Sickle Cell Disease and Hyphema
    1. Beta Blockers
    2. Clonidine
  6. Avoid medications in Sickle Cell Disease that cause sickling
    1. Acetazolamide (Diamox)
    2. Diuretics
    3. Mannitol
    4. Topical beta agonists (e.g. Epinephrine)
  • Complications
  1. Blindness
    1. Results from Hyphema rebleeding (from dislodged clot)
  2. Corneal blood staining
  3. Glaucoma
  4. Retinal Injury
  • 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
  • References
  1. Majoewsky (2012) EM:Rap 12(1): 4
  2. Glassberg and Weingart in Majoewsky (2012) EM:Rap 12(9): 3-4