HYPHEMA

SIGNS AND SYMPTOMS

Patients may present with blurred vision, pain, photophobia
and tearing following blunt, concussive injury to the eye or
orbit. Hyphemas (blood in the anterior chamber) are
described by the amount of anterior chamber (AC) they
occupy
!rade " # less than one$%uarter of the visible volume of the
AC
!rade & # one$%uarter to one$half of the visible volume of the
AC
!rade ' # one$half to three$%uarters of the visible volume of the AC
!rade ( # complete filling of the visible AC
)he term *eight$ball hemorrhage* is reserved for completely filled anterior chambers with
blac+$colored clots.
PATHOPHYSIOLOGY
)here are two suggested mechanisms of hyphema formation. ,ither direct, contusive forces
cause mechanical tearing of the fragile blood vasculature of the iris and-or angle, or
concussive trauma creates rapidly rising intravascular pressure within these vessels, resulting
in rupture.
.lood in the AC is not by itself necessarily harmful. However if %uantities are sufficient it
may obstruct the outflow of a%ueous humor, resulting in glaucoma. Hemolytic glaucoma
results from direct obstruction of the trabecular meshwor+ by fresh blood. Hemosiderosic
glaucoma results from trabecular meshwor+ obstruction from degrading hemoglobin. !host
cell glaucoma results from trabecular meshwor+ obstruction by the s+eletons of the
disintegrating red blood cells. /inally, any e0ternal force strong enough to produce internal
bleeding is also sufficiently strong to produce direct damage to the adjacent trabecular
meshwor+, resulting in sluggish a%ueous drainage (late glaucoma).
MANAGEMENT
A thorough history is critical. Circumstances surrounding the event, current medicines and
previous ocular history are important pieces of data. .leeding in the eye warrants %uestioning
concerning systemic blood disorders such as sic+le cell anemia, hemophilia and 1on
2illebrand3s disease (vascular hemophilia). 4f the patient is a poor historian or %uestions arise
regarding systemic health, order systemic tests for sic+le cell anemia (sic+le prep or sic+le
de0) and bleeding disorders (P) and P))).
5cular e0amination should include an evaluation of the adne0a (6$ray, C) scan to rule out
fracture or entrapment) cornea (to rule out perforation), sclera (to rule out ruptured globe),
anterior chamber, lens, vitreous and retina. 4f a clear view of the fundus is obstructed by the
hyphema or vitreous hemorrhage, perform or refer for a .$scan ultrasound of the globe.
2hether these individuals should be hospitali7ed is controversial. 8ost practitioners manage
uncomplicated hyphemas (grade ") without hospital admission. Cycloplege the patient with
atropine "9 .4:-;4: and prescribe a steroid such as Pred /orte or 1e0ol ;&H-;4:. 4f
intraocular pressure is above &<mm Hg, it should be controlled using topical beta$bloc+ers
.4:. 2hen 45P re%uires acute attention (i.e., over '=mm Hg) prescribe aceta7olamide =>>mg
P5 .4:, barring systemic contraindications, until the pressure is ade%uately controlled. 4f
there are corneal epithelial defects, ?0 a topical antibiotic prophylactically. 4nstruct the patient
to limit activity to the bathroom and bed rest, laying with the head elevated at an angle of '>
degrees. Provide an eye shield for additional protection.
)o prevent re$bleeding, use only acetaminophen to manage pain@ avoid aspirin and ibuprofen.
?eferral for surgical evaluation is indicated if there is corneal blood staining, if 45P is greater
than A>mm Hg, if there is an eight$ball hemorrhage or if the 45P remains above '= for seven
days. /ollow up with 1A, slit lamp, 45P and dilated fundus e0am for four consecutive days,
then as necessary.
CLINICAL PEARLS
!onioscopy is contraindicated because it increases the ris+ of re$bleeding. However,
up to => percent of patients with hyphema possess angle recession and the possibility
of developing a secondary traumatic late glaucoma. 8onitor the 45P of these patients
regularly. )he onset of secondary glaucoma is between "& months and => years.
Perform gonioscopy after the event has resolved and the ris+ of re$bleeding has
passed.
Aminocaproic acid (Amicar =>mg-+g), an antifibrinolytic, has been advocated by
some to reduce the ris+ of re$bleeding. 5ne of its potential side effects is severe nausea
and vomiting, a contraindication in patients with hyphema. )he medicine seems to
function best in children but is not universally accepted and remains controversial.
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