Thank you Dr. Osagie for this Morning Report
Emergency Medicine Management of Traumatic Hyphema
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):
-Eye tumors such as iris melanoma, retinoblastoma
-Clotting disorders (thrombocytopenia, hemophilia, Von Willebrand disease)
-Sickle cell anemia
-Medications that inhibit platelet function (warfarin/ ASA)
Presentation/ exam findings:
-Decreased visual acuity
-Anisocoria relative to the unaffected eye (torn iris sphincter muscles – miosis/mydriasis)
-Elevated intraocular pressure (>21mmHg); 30 percent of patient’s with hyphema and can occur acutely and days after injury (thus close follow up is essential); patients with sickle cell disease or trait are at high risk for elevation of intraocular pressure within first 24 hours
-Corneal blood staining – diffusion of RBC breakdown products into the corneal stroma causing a golden discoloration of the cornea
***Look for Signs of open globe ***– Physical findings of globe rupture include:
●Markedly decreased visual acuity ●Eccentric pupil
●Increased anterior chamber depth ●Low intraocular pressure
●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 (SEE ATTACHED)
-Diagnostic tests: Your eye exam (DO NOT MEASURE IOP if RUPTURED GLOBE IS SUSPECTED), Emergent ophthalmology evaluation, orbital CT, labs (especially If on anticoagulation)
-Elevate the bed of the bed 45 degrees/ bed rest
-Pain control (avoid NSAIDS)/Antiemetic
–Cycloplegic eye drops – such as atropine 1% à prevents pupillary movement thus limiting further movement of 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) ***(intravascular hemoconcentration and increased microvascular sludging, both of which are detrimental in sickle cell hemoglobinopathy.)
Topical steroids – decrease complications due to intraocular inflammation
ANTIFIBRINOLYTICS – Promote blood clotting by prevent blood clot degradation -Used in hyphemas occupying 75% or less of the anterior chamber because the clot may persist in the anterior chamber during drug administration. The continued retention of the clot in the anterior chamber could be a potential disadvantage with larger Grade 4 hyphemas.
*** A 2013 Cochrane review concluded that the antifibrinolytics, aminocaproic acid (ACA) – both topical and systemic, tranexamic acid, and aminomethylbenzoic acid all reduced the rate of secondary hemorrhage
A more recent prospective study used tranexamic acid (5%) eye drop every 6 hours for 5 days. The main outcome measures were best corrected visual acuity (BCVA), Intra-ocular pressure (IOP), day of clot absorption, and rate of rebleeding. (small study of 30 patients)
****Like ACA, tranexamic acid has been associated with nausea, vomiting, and hypotension. Unlike ACA, tranexamic acid is associated with visual abnormalities, which could complicate the ophthalmologic evaluation of the patient.
-Hyphema occupies less than 33% of the anterior chamber
-PATIENT MUST BE ABLE TO FOLLOW UP – Daily ocular examinations, including an evaluation of the amount of hyphema and intraocular pressure, should be performed.
-Hyphema occupies more than 33% of the anterior chamber and/or intraocular pressure is elevated beyond 30 mm Hg
-The decision to hospitalize also depends on the cooperation of the patient and family members, and the extent of ocular injury.
Content reviewed by Dr. deSouza
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.