Hyphema

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Facial Trauma: Hyphema

Hyphema
Inline image 1
Hyphema results from ocular trauma that causes bleeding into the anterior chamber. The bleeding originates from vessels in the ciliary body or iris. The blood tends to layer over time, and left undisturbed, will form a visible meniscus when the patient sits upright. Patients typically complain of pain, photophobia, and possibly blurred vision secondary to obstructing cells. Intraocular pressure should be measured because acute glaucoma may be caused by RBC clogging of the trabecular meshwork with impedance to aqueous outflow. Prevention of further hemorrhage is the principal treatment goal. Most rebleeding occurs within the first 72 hours and, when present, tends to be more extensive than the initial event. Patients should be instructed to rest in the supine position with their head slightly elevated. In addition, carbonic anhydrase inhibitors should be avoided in patients with sickle cell anemia because they can cause RBCs to sickle in the anterior chamber, which can lead to increased IOP.
There are 4 grades of Hyphema. Below is an image showing the grades and 
 
Inline image 2
 
Evaluation - Best done under a slit-lamp exam. Watch the videos below for  
 
Dr. Anna Pickens has great videos on the slit-lamp exam and hyphema, please watch below: 
 
1. Slit Lamp: https://emin5.com/2016/02/07/slit-lamp-anatomy/
2. Hyphema: https://www.youtube.com/watch?v=vQG9kL7mpyA 
  • 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
 
Management
 
  • 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 (>22) 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 α-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 α-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)
    • Homatropine
    • 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
  • Patients on anticoagulation or anti-platelets agents should be admitted for reversal and observation.
Discharge Instructions
  • No reading (accommodation may further stress injured blood vessels)
  • Avoid NSAIDs
  • Wear hard shield at all times
  • 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%
Sources: EM in 5, Rosh Review, Wikem.
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