para>Seidel sign is seen when fluorescein placed into the eye streams down like a waterfall; it is a sign of globe rupture.
Never check intraocular pressure or place any pressure on the orbit without first ruling out globe rupture.
Blood can obstruct outflow and cause the intraocular pressure to become dangerously high; this elevated pressure can cause staining of the cornea and lead to optic atrophy.
Having the patient sit upright will facilitate layering of red blood cells.
Grading system: Grade 1 occupies less than 1/3 of the anterior chamber, grade 2 occupies 1/3-1/2, grade 3 occupies more than 1/2, and grade 4 refers to totally clotted blood.
Differential Diagnosis
- Globe rupture
- Conjunctivitis
- Corneal abrasion
- Corneal ulcer
- Hypopyon
- Traumatic iritis
- Neovascularization
- Neoplasm
- Uveitis
- Child abuse
Diagnostic Tests & Interpretation
Initial Tests (lab, imaging)
- Patients with known or suspected blood dyscrasias should have a complete blood count (CBC) and coagulation (prothrombin time [PT]/international normalized ratio [INR]) checked.
- Consider a sickle cell preparation or hemoglobin electrophoresis in African American patients in whom sickle cell trait or disease is being considered.
- CT scan of the orbits for patients with suspected open globe injury or with concern for intraocular foreign body (2)
- CT scan of the facial bones should be done if concomitant facial fractures are suspected.
- B-scan ultrasonography may also be useful but should never be done in cases of suspected globe rupture.
- Iris fluorescein angiogram may be performed if iris neovascularization is suspected as the underlying cause.
Treatment
General Measures
Alert
If globe rupture is suspected, place an eye shield and consult ophthalmology immediately; no further examination or testing should be done.
Place the patient in a dark room with the head of the bed at 30 degrees.
No reading (to prevent accommodation).
Consider oral or intravenous (IV) opioid medication if pain remains uncontrolled.
Antiemetics for nausea/vomiting
Treat pain and vomiting aggressively to prevent a sudden rise in intraocular pressure.
Reverse coagulopathies.
Alert
Avoid aspirin and nonsteroidal anti-inflammatory medications, which may worsen bleeding.
Medication
First Line
- Tetracaine 0.5% 1-2 gtts once to affected eye (topical analgesia)
- Atropine 0.5%, 1%, or 2% 1-2 drops b.i.d.-t.i.d. (for cycloplegia)
Second Line
- Topical steroids such as prednisolone 1% 1 drop q.i.d.-q1h can prevent rebleeding.
Alert
Always consult an ophthalmologist prior to using topical steroids, as risk of subsequent corneal ulcer and perforation is then increased.
Alert
Systemic glucocorticoids have not shown to be of benefit (1)[C].
Treat intraocular hypertension with timolol 0.5% q12h, topical carbonic anhydrase inhibitors such as dorzolamide (Trusopt) 2% t.i.d., and if necessary, acetazolamide (Diamox) 500 mg PO b.i.d. or 500 mg IV.
Clinical alert: Avoid acetazolamide if there is concern for sickle cell disease.
Consider aminocaproic acid 50 mg/kg PO q4h (up to 30 g daily) for 5 days or tranexamic acid 25 mg/kg q8h for 5 days in patients with traumatic hyphema who present with rebleeding (3,4)[A].
Alert
Aminocaproic acid can cause severe nausea and vomiting.
Issues for Referral
- To manage associated injuries such as globe rupture or facial fractures
- When considering topical steroids
- Patients with sickle cell trait or disease or other bleeding dyscrasias
- In the presence of intraocular hypertension
Additional Therapies
- Limiting physical activity may be of benefit.
- An eye shield should be worn for at least 1 week or until the hyphema has resolved.
- An eye patch is not recommended.
Surgery/Other Procedures
- Usually indicated on or after the fourth day
- Indications include uncontrolled intraocular hypertension despite maximal medical management, microscopic corneal bloodstaining, a grade 3 hyphema for more than 8 days, or a grade 3 hyphema for more than 6 days.
Alert
Uncontrolled intraocular hypertension is defined as >50 mm Hg for 4 days, >35 mm Hg for 7 days, or >25 mm Hg for >24 hours in patients with sickle hemoglobinopathy.
Inpatient Considerations
Admission Criteria/Initial Stabilization
- Most patients can be treated in the outpatient setting.
- Consider admission for associated injuries such as globe rupture, intraocular hypertension, coagulopathies, suspected cases of abuse, and large hyphemas that occupy >50% of the anterior chamber.
Ongoing Care
Follow-up Recommendations
In cases of traumatic hyphema, patients should have daily recordings of intraocular pressure performed.
Patient Education
- Patient education and compliance is essential for successful outcomes.
- Sudden decrease in vision or increase in pain raises suspicion for rebleeding and possible intraocular hypertension.
- Appearance of new floaters or complaints of a shade lowering over the eye raises concern for retinal detachment.
Prognosis
- Uncomplicated hyphemas typically resolve in 5-6 days.
- Patients with sickle cell trait or disease are at higher risk of permanent vision loss.
- Traumatic hyphema following a blunt eye injury increases long-term risk of developing glaucoma.
- Secondary rebleeding markedly increases the risk of vision loss and is typically larger than the initial bleed.
Complications
- Secondary rebleeding occurs in approximately 25% of all patients and incidence is inversely related to age.
Alert
Secondary rebleeding most often occurs on day 3 or 4.
Alert
Rebleeding or secondary hemorrhages are typically larger than the initial one and may increase risk for vision loss.
References
1.Walton W, Von Hagen S, Grigorian R, et al. Management of traumatic hyphema. Surv Ophthalmol. 2002;47(4):297-334.
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2.Arey ML, Mootha VV, Whittemore AR, et al. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology. 2007;114(8):1448-1152.
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3.Salvin JH. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007;18(5):366-372.
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4.Pieramici DJ, Goldberg MF, Melia M, et al. A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid in the management of traumatic hyphema. Ophthalmology. 2003;110(11):2106.
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5.Gharaibeh A, Savage HI, Scherer RW, et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2013;12:CD005431.
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Codes
ICD09
- 921.3 Contusion of eyeball
- 364.41 Hyphema of iris and ciliary body
ICD10
- S05.10XA Contusion of eyeball and orbital tissues, unsp eye, init
- H21.00 Hyphema, unspecified eye
SNOMED
- 231954005 Traumatic hyphema
- 75229002 Hyphema (disorder)
- 303019009 Spontaneous hyphema (disorder)
Clinical Pearls
- Hyphema is a collection of red blood cells in the anterior chamber that often results from trauma.
- Once globe rupture has been excluded, a thorough examination for associated injuries and raised intraocular pressure should be performed.
- Treatment and disposition decisions should, in most cases, be made in consultation with an ophthalmologist.