Traumatic Hyphema - What is it and how should it be treated?

What is it? Grossly visible blood in the anterior chamber of the eye

Microhyphema: dispersed red blood cells in the anterior chamber

Why does it occur?

Bleeding results from tears in the vessels of the ciliary body or iris
Bleeding usually stops quickly due to increased intraocular pressure, vessel spasm, and/or formation of a clot
Non-traumatic causes (due to neovascularization of vascular anomalies of the anterior chamber structures):
- Diabetes Mellitus
- Eye tumors such as iris melanoma, retinoblastoma
- Clotting disorders (thrombocytopenia, hemophilia, Von Willebrand disease)
- Sickle cell anemia
- Medications that inhibit coagulation/platelet function (warfarin/ASA)

Presentation/ physical exam findings:

Photophobia
Decreased visual acuity
Anisocoria
- Due to torn iris sphincter muscles – miosis/mydriasis
Elevated intraocular pressure (>21mmHg)
- 30% of patient’s with hyphema develop increased IOP which can occur acutely or days after injury, thus close follow up is essential.
- Patients with sickle cell disease or trait are at high risk for elevated IOP within first 24 hours
Corneal blood staining
- Diffusion of RBC breakdown products into the corneal stroma causing a golden discoloration of the cornea
OPEN GLOBE
- Markedly decreased visual acuity
- Eccentric pupil
- Increased anterior chamber depth
- Low intraocular pressure (however you shouldn’t be testing this if you suspect open globe)
- Extrusion of vitreous
- Tenting of the cornea or sclera at the site of globe puncture
- Seidel’s sign (SIGH-DEL): fluorescein streaming in a tear drop pattern away from the puncture site

Grading scale

Diagnostic tests:

Your eye exam (REMEMBER: DO NOT MEASURE IOP IF RUPTURED GLOBE IS SUSPECTED)
Emergent Ophthalmology evaluation
Orbital CT
Labs – particularly if patient is on anticoagulation

Treatment:

Eye shield
Bed rest
Elevate the bed of the bed 45 degrees
Pain control – avoid NSAIDS
Antiemetic
Cycloplegic eye drops: atropine 1% prevents pupillary movement, thus limiting further movement of the torn iris vessels and promoting tamponade
Treatment of raised IOP is usually accomplished initially with the use of a topical β-blocker such as 0.5% timolol, which acts to decrease the production of aqueous humor. Topical α2-agonist therapy with an agent such as brimonidine can also be used. Systemic acetazolamide, a carbonic anhydrase inhibitor, also decreases production of aqueous humor (500mg IV or PO). Hyperosmolar therapy with mannitol reduces total volume of aqueous humor through the generation of an osmotic gradient, drawing fluid into the intravascular space (1 to 2 g/kg IV).

Other Considerations

Topical steroids: decrease complications from intraocular inflammation
Oral steroids
Anti-fibrinolytics: Promote hemostasis by preventing blood clot degradation
- Used in hyphemas occupying 75% or less of the anterior chamber. The clot may persist in the anterior chamber during drug administration which could be a potential disadvantage in larger hyphemas.
- A 2013 Cochrane review concluded that anti-fibrinolytics – aminocaproic acid (ACA), tranexamic acid (TXA) and aminomethylbenzoic acid – all reduced the rate of secondary hemorrhage.
- A more recent prospective study used TXA eye drops (5%) every 6 hours for 5 days. The main outcome measures were: best corrected visual acuity (BCVA), intraocular pressure (IOP), day of clot absorption and rate of rebleeding.
- Like ACA, TXA has been associated with nausea, vomiting, and hypotension. Unlike ACA, TXA acid is associated with visual abnormalities, which could complicate the ophthalmologic evaluation of the patient.

Disposition

Outpatient: hyphema occupies less than 33% of anterior chamber

Patient must be able to follow up for daily ocular exams – for resolution of hyphema and IOP measurement

Inpatient: hyphema occupies more than 33% of the anterior chamber and/or IOP is elevated beyond 30 mmHg

Content reviewed by Dr. deSouza

References:

Allingham RR, Crouch ER Jr, Williams PB, et al. Topical aminocaproic acid significantly reduces the incidence of secondary hemorrhage in traumatic hyphema in the rabbit model. Arch Ophthalmol. 1988 Oct. 106(10):1436-8. [Medline].

Pieramici DJ, Goldberg MF, Melia M, et al. A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. Ophthalmology. 2003 Nov. 110(11):2106-12. [Medline].

Gharaibeh A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2013 Dec 3. 12:CD005431.