Traumatic hyphema

Background

• Grossly visible blood in the anterior chamber of the eye
• Typically caused by blunt trauma to the orbit
• Can result in permanent vision loss
  • Outcome dependent on prevention of rebleeding and control of intraocular pressure
• In non-traumatic hyphema, all Black patients should be screened for sickle cell disease with hemoglobin electrophoresis

Clinical Features

Hyphema, Grade II-III

• Vision loss
  • Earliest symptom is decreased vision
• Eye pain
• History of trauma to eye
• Direct and consensual photophobia
• Nausea and Vomiting
• Hyphema grading correlates to IOP increase
  • Grade 0 to IV
  • 13.5% have IOP increase in Grade I to II
  • 52% with IOP increase in Grade IV

Differential Diagnosis

• Retinal detachment

Maxillofacial Trauma

• Le Fort fractures
• Skull fracture (peds)
• Auricular hematoma
• Nasal fracture
  • Nasal septal hematoma
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Dental trauma
• Mandible fracture

Orbital trauma

Acute

• Ruptured Globe^
• Corneal Abrasion
• Ocular foreign body
• Conjunctival laceration
• Caustic Keratoconjunctivitis^^
• Subconjunctival hemorrhage
• Traumatic iritis
• Traumatic hyphema
• Retinal detachment
• Retrobulbar hemorrhage/hematoma
• Traumatic mydriasis
• Orbital fracture
  • Frontal sinus fracture
  • Naso-ethmoid fracture
  • Inferior orbial wall fracture
  • Medial orbital wall fracture

Subacute/Delayed

• Endophthalmitis^
• Corneal Ulcer^

Unilateral Red Eye

• Acute angle-closure glaucoma^
• Anterior uveitis
• Caustic keratoconjunctivitis^^
• Conjunctival laceration
• Conjunctivitis
• Corneal abrasion
• Corneal erosion
• Ocular foreign body
• Corneal ulcer^
• Endophthalmitis^
• Episcleritis
• Globe rupture^
• Herpes zoster ophthalmicus
• Intraocular foreign body
• Inflamed pingueculum
• Inflamed Pterygium
• Keratoconjunctivitis
• Keratoconus
• Lens dislocation
• Nontraumatic iritis
• Scleritis^
• Subconjunctival hemorrhage
• Traumatic hyphema
• Traumatic iritis
• Ultraviolet keratitis

^Emergent diagnoses

^^Critical diagnoses

Spontaneous hyphema (non-traumatic hyphema)

• Sickle cell disease
• Ocular or laser surgery
• HSV, VZV uveitis
• Neoplastic

Evaluation

evaluation is best performed under slit-lamp exam

• Blood in anterior chamber
  • May only see difference in color of irises if patient is supine because blood layering is gravity dependent
  • Blood in anterior chamber only visible on slit lamp is a microhyphema
• Vision loss / Acuity changes
• Inspect the lids, lashes, lacrimal ducts, and cornea
  • Corneal abrasions often co-exist
• Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect
• Assess for Ruptured Globe which is associated with high energy mechanisms (shrapnel, BB guns, paint balls, etc)
• Check intraocular pressure after Globe Rupture is excluded
• Inquire about bleeding diathesis, anticoagulant/NSAID/aspirin use

Managment

• Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs
• Eye shield
• Pharmacologic control of pain and emesis
• Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants
• If IOP elevated the treatment is similar to glaucoma management except if there is also a concern for a retrobulbar hematoma as a result of trauma. Topical and oral treatments include
  • Timolol
  • Topical alpha-adrenergic agonist
  • Carbonic anhydrase inhibitors
• Consult ophtho regarding:
  • Dilation of pupil to avoid "pupillary play" -constriction and dilation movements of the iris in response to changing lighting, which can stretch the involved iris vessel causing additional bleeding
  • Use of topical alpha-agonists and/or acetazolamide to decrease intraocular pressure
• Cycloplegic can be given for comfort and to decease pupillary play if globe rupture has been excluded. Options include:
  • Tropicamide (Mydriacyl)
  • Homoatropine
  • Cyclopentolate (Cyclogyl, Cylate, Pentolair)
  • Scopolamine
• Topical steroid
• Treat any underlying coagulopathy

Disposition

• Should be made by the ophthalmologist after examining the patient
  • Hyphemas <33% of anterior chamber are frequently managed as outpatients
• Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hypthemas due to the association with sickle cell disease and hemophilia

Discharge instructions

• No reading (accommodation may further stress injured blood vessels)
• Return to ED if rapid increase in size of hyphema or large increase in pain

Prognosis

• Rebleeding worsens prognosis as patients are at higher risk of permanent vision loss.
  • Occurs 3-5 days after initial incident
  • Complicates ~30% of cases
  • Populations at highest risk:
    • Sickle cell disease or sickle cell trait
    • Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
    • Initial intraocular pressure >22 mmHg
    • Pediatric patients

Grade	Anterior Chamber Filling	Normal Vision Prognosis
I	<33%	90%
II	33-50%	70%
III	>50%	50%
IV	100%	50%

See Also

• Blunt orbital trauma

References

Authors

Ross Donaldson