Hyphema, Emergency Medicine

Basics

Description

Blood in anterior chamber (AC) of the eye (between iris and cornea).
Hyphema: Grossly visible layering of blood.
Microhyphema: Suspended RBCs visible by slit-lamp only.
Genetics:
- Genetic predisposition is related to hereditary blood dyscrasias (see below).

Etiology

Blunt trauma: Most common (70-80%).
Anteroposterior compression of the globe with simultaneous equatorial globe expansion causing rupture of iris stromal/ciliary body vessels
Penetrating trauma: Direct injury to stromal vessels or sudden ocular decompression.
Spontaneous: Less common, lower incidence of complications:
- Tumors:
  - Melanoma
  - Retinoblastoma
  - Xanthogranuloma
  - Metastatic tumors
- Blood dyscrasias:
  - Hemophilia
  - Leukemia
  - Thrombocytopenia
  - Von Willebrand disease
- Blood thinners: Aspirin, Coumadin, heparin
- Neovascularization of iris: In proliferative diabetic retinopathy, retinal vein occlusion, carotid stenosis.
- Postsurgical: Cataract extraction, trabeculectomy, pars plana vitrectomy.

In children with no history of trauma, suspect child abuse.

Diagnosis

Signs and Symptoms

Photophobia
Blurring of vision
Decreased visual acuity
Ocular pain
Nausea/vomiting

History

Previous visual acuity
Prior eye surgery
Prior glaucoma treatment.
Past medical history (blood disorders including sickle cell disease).
Mechanism of trauma.
Exact time of injury and of visual loss.
History of excessive tearing after injury.

History of excessive tearing may indicate open globe injury.
Physical Exam

General physical exam with emphasis on associated bodily injuries.
Periorbital ecchymosis
Eyelid lacerations
Enophthalmos (depression of the globe within the orbit)
Limited ocular movement with diplopia (may indicate orbital floor fracture)
Proptosis (may indicate retro-orbital hemorrhage)
Ocular exam:
- Visual acuity
- Rule out open globe (positive Seidel sign, corneal laceration, diffuse subconjunctival hemorrhage, decreased ocular motility, prolapse of intraocular structures)
- Pupillary reaction to light (check for afferent pupillary defect prior to using dilating drops)
- Tonometry for intraocular pressure (IOP) measurement

Exclude open globe injury before measuring IOP

Slit-lamp exam; look for layer of blood in AC:
- 4 grades of hyphema depending on percentage of AC occlusion by blood:
  - Grade I: <1/3
  - Grade II: 1/3-1/2
  - Grade III: >1/2
  - Grade IV: Total (called 8-ball hyphema; blood is dark and filling 100% of AC)
- High-grade hyphemas are:
  - More likely to rebleed (25% of grade I compared with 67% of grade III)
  - More likely to develop glaucoma and corneal staining
  - Less likely to recover visual acuity
- Dilated fundus exam (avoid pressure on globe)

Diagnosis Tests & Interpretation

Lab

Lab tests should be individualized depending on the case.
Platelet count, PT/PTT, bleeding time if bleeding disorder is suspected, or if the patient is on anticoagulants.
BUN, creatinine, and pregnancy test if aminocaproic acid is to be used (see below)
Factor VIII assay if family history of hemophilia
Sickle cell screen especially in African Americans and Mediterranean descent

Imaging

CT orbits (1 mm cuts) if open globe injury, intraocular foreign body, or orbital wall fracture is suspected
US biomicroscopy (B scan) if total hyphema and intraocular structures cannot be visualized.

Do not perform B scan if open globe injury is suspected (pressure applied during this procedure may cause extrusion of intraocular contents).

Essential Workup

Exam: Visual acuity, status of globe, IOP, associated ocular/bodily injuries
Labs: Platelet count, PT/PTT, and sickle cell screen if indicated
Imaging: B scan or CT orbits if indicated

Differential Diagnosis

Uveitis
Endophthalmitis

Treatment

Pre-Hospital

Place eye shield in case of corneal perforation or suspected open globe injury.

Initial Stabilization/Therapy

Keep head upright to allow blood in AC to settle down.
Limit activity; avoid bending, straining, or exertion.
Place metal or plastic shield over involved eye until integrity of globe is confirmed.
Do not patch affected eye (if eye is patched, patient cannot notice sudden loss of vision).
Note that metal and plastic shields have holes that let patient see through whereas patch completely blocks patients vision.

Ed Treatment/Procedures

Mild analgesics (avoid NSAIDs because of antiplatelet effect)
Antiemetics (associated N/V may worsen hyphema by increasing IOP)
Cycloplegics decrease pain from iritis:
- Atropine 1% or cyclopentolate 1% eye drops: BID-TID until hyphema resolves.
Topical steroids may decrease inflammation from iritis:
- Prednisolone acetate: 1% eye drops (or equivalent) 4-8 times per day until hyphema resolves (usually 7-10 days).
Aminocaproic acid (antifibrinolytic):
- Use in consultation with ophthalmologist:
  - Not commonly used because of frequent systemic side effects.
- Stabilizes fibrin clot in AC and decreases incidence of rebleed, but has no effect on final visual outcome.
- 50 mg/kg PO q4h for total of 5 days (do not exceed 30 g/day). Dose should be adjusted in renal failure.
- May cause postural hypotension, nausea, vomiting, diarrhea.
- New topical form is not yet FDA approved.
- Do not use in pregnant women or in patients prone to thrombosis. It can also cause acute renal failure in patients with hemophilia.
Oral prednisone:
- Indications:
  - Hemophilia
  - Uncooperative children
  - Total hyphema
  - History of thrombotic disease
- Dose: 0.6-0.75 mg/kg/24 hr in div. doses, up to 60 mg/day for 5 days
For increased IOP:
- For non-sickle cell patients, treat if IOP >30 mm Hg.
- For sickle cell patients, treat if IOP >24 mm Hg.
- Treat until IOP is controlled as indicated above.
- Always start with 1 medication. Add another if unsuccessful in controlling pressure:
  - β-blockers-drug of choice: Timolol or Levobunolol 0.5% BID
  - Î±-agonist: Brimonidine 0.2% or apraclonidine 0.5% TID
  - Topical carbonic anhydrase inhibitors (CAI): Dorzolamide 2% or brinzolamide 1% TID
  - Oral CAI: Acetazolamide 500 mg PO q12h (peds: 8-30 mg/kg/24 hr q6-8h) or methazolamide 50 mg q8h.
  - Mannitol (1-2 mg/kg IV over 45 min q24h) when all other eye drops fail to lower IOP to acceptable level.
  - Avoid CAI and Mannitol in sickle cell patients, as they may cause acidosis and induce sickling.
- Allow 25-30 min for each eye drop to work. If after using all the drops and mannitol, IOP is still high, then surgical evacuation of blood clot is warranted (AC tap or washout).
Drugs to avoid:
- Pilocarpine: Constricts pupil and prevents visualization of lens and retina
- Prostaglandin eye drops (e.g., Latanoprost): Increase inflammatory response

Criteria for immediate consultation with ophthalmologist from the ED (If possible, consultation should be arranged within 24 hr.):

Visual acuity worse than 20/200 at presentation.
Sickle cell disease/trait with high IOP
Large hyphema (filling >1/3 of AC).
Medically uncontrolled IOP.
Suspected open globe injury

Medication

First Line

Atropine: 1% TID
Prednisolone acetate: 1% QID

Second Line

Timolol 0.5% or levobunolol 0.5% BID
Brimonidine 0.2% or apraclonidine 0.5% TID
Dorzolamide 2% or brinzolamide 1% TID
Acetazolamide: 500 mg PO q12h.

Follow-Up

Disposition

Discharge patient on atropine, prednisolone, and any appropriate IOP-lowering medications.
Continue aminocaproic acid if decision was made to start it in ED.
Antiemetics if needed.
Stool softeners to minimize straining during bowel movements.

Admission Criteria

Hyphema size is not a criterion for discharge or admission; IOP control is the most important factor.
Medically uncontrolled IOP requiring surgical intervention
Ruptured globe
Noncompliant patients
Associated ocular or orbital injuries
Children <7 yr of age:
- Age group is usually at risk of amblyopia (also called lazy eye, which is irreversible visual loss secondary to visual deprivation in early childhood).
Patients at risk of complications (sickle cell disease, hemophilia).

Discharge Criteria
Absence of any admission criteria with IOP <30 mm Hg for non-sickle patients and <24 mm Hg for patients with sickle cell disease/trait.

Followup Recommendations

Arrange for follow-up with ophthalmologist:

Daily slit-lamp exam for 3 days after initial trauma to monitor for rebleeding, corneal staining, and increased IOP.
Follow-up exam will determine length of treatment with atropine, prednisone acetate, and IOP-lowering eye drops.

Pearls and Pitfalls

Rule out ruptured globe prior to checking IOP and prior to initiating treatment.
IOP control is not immediate. Allow at least 30 min for any treatment to take effect:
- Always check for sickle cell disease in African Americans.

Additional Reading

Berke S. Post-traumatic glaucoma. In: Yanoff M, Duker J, eds. Ophthalmology. 2nd ed. St. Louis, MO: Mosby; 2004:1518-1521.
Crouch ER Jr, Crouch ER. Management of traumatic hyphema: Therapeutic options. J Pediatr Ophthalmol Strabismus. 1999;35(5):238-250.
Culom RD Jr, Chang B., eds. Hyphema and microhyphema. In: Rhee DJ, Pyfer MF, eds. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1999:32-37.
Hamill MB. Current concepts in the treatment of traumatic injury to the anterior segment. Ophthalmol Clin North Am. 1999;12(3):457-464.
Sankar PS, Chen TC, Grosskrentz CL, et al. Traumatic hyphema. Int Ophthalmol Clin. 2002;42(3):57-68.
Walton W, Von Hagen S, Grigorian R, et al. Management of traumatic hyphema. Survey Ophthalmol. 2002;47(4):297-334.

Codes

ICD9

364.41 Hyphema of iris and ciliary body
921.3 Contusion of eyeball

ICD10

H21.00 Hyphema, unspecified eye
S05.10XA Contusion of eyeball and orbital tissues, unsp eye, init
S05.12XA Contusion of eyeball and orbital tissues, left eye, init
S05.11XA Contusion of eyeball and orbital tissues, right eye, init
H21.01 Hyphema, right eye
H21.02 Hyphema, left eye
H21.03 Hyphema, bilateral
H21.0 Hyphema

SNOMED

231954005 Traumatic hyphema
75229002 Hyphema (disorder)

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