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Hyphema

Hyphemas

Hyphema is characterized by either collection of blood or bleeding in the region between cornea and iris of eye. The blood gets collected in a manner that it covers almost the entire part of the pupil and iris causing blurred vision.


Presentation

A small hyphema will be difficult to locate when the eye is seen in the mirror. However, in case of total hyphema, it can even block the iris and pupil, which would cause blurred vision. Individuals with hyphema would present with the following signs and symptoms:

  • Visible blood collection in the affected eye
  • Eyes cannot tolerate light and become sensitive towards it
  • Pain in the affected eye
  • Vision gets blocked due to development of total hyphema
  • Blurred vision
Easy Bruising
  • In idiopathic hyphemas in patients with easy bruising, pallor, or complaints of fatigue, hematological evaluation should be considered.[emedicine.com]
Cervical Lymphadenopathy
  • A left vascular conjunctival mass and massive cervical lymphadenopathy occurred 7 months later. Biopsy revealed extraocular retinoblastoma and lymph node metastasis. Computed tomography showed an intraocular mass with intracranial extension.[ncbi.nlm.nih.gov]
Lymphadenopathy
  • A left vascular conjunctival mass and massive cervical lymphadenopathy occurred 7 months later. Biopsy revealed extraocular retinoblastoma and lymph node metastasis. Computed tomography showed an intraocular mass with intracranial extension.[ncbi.nlm.nih.gov]
Disability
  • A total of 94.7% of patients had an IOP CONCLUSIONS: Traumatic hyphema is a recognized cause of significant visual disability. Improved visual acuity was attained after 3 months. The presenting visual acuity correlated with the visual prognosis.[ncbi.nlm.nih.gov]
Asymptomatic
  • Other patients are asymptomatic and diagnosed with hyphema or anterior chamber red blood cells on routine examination. The hyphema often resolve spontaneously, making later diagnosis difficult.[ncbi.nlm.nih.gov]
Intravenous Administration
  • As there were no eruptions on his face or body, we diagnosed zoster sine herpete and started intravenous administration of prednisolone and acyclovir.[ncbi.nlm.nih.gov]
Dyspnea
  • Aminocaproic acid is reported to have several side effects including nausea, vomiting, muscle cramps, conjunctival suffusion, headache, rash, pruritis, dyspnea, toxic confusional states, arrhythmias, and systemic hypotension.[doi.org]
Purpura
  • Other problems to be considered Trauma Intraocular surgery Spontaneous hyphema Iris microhemangiomas, iris varix, and pupillary microhemangiomas Iris neovascularization Bleeding diatheses or clotting disturbances such as idiopathic thrombocytopenic purpura[emedicine.com]
Skin Lesion
  • Slit-lamp examination demonstrated hyphema, anterior chamber inflammation, mid-dilated pupil, impaired corneal sensation, and high intraocular pressure, without any facial skin lesions.[ncbi.nlm.nih.gov]
  • Typical herpes zoster involving the first branch of the trigeminal nerve with skin lesions is called herpes zoster ophthalmicus (HZO), whereas recurrence of herpes zoster without skin lesions is known as zoster sine herpete (ZSH).[bmcophthalmol.biomedcentral.com]
Flushing
  • METHODS: The ACM was used to reform and maintain the anterior chamber, and to flush out the clotted blood. The ACM cannula was inserted at the 6 o'clock position, and then a 2-mm-width contra lateral limbal incision was made.[ncbi.nlm.nih.gov]
  • Slit lamp examination typically reveals perilimbial conjunctival injection or “ciliary flush” and cells and flare in the anterior chamber.[canadiem.org]
Eruptions
  • As there were no eruptions on his face or body, we diagnosed zoster sine herpete and started intravenous administration of prednisolone and acyclovir.[ncbi.nlm.nih.gov]
Low Back Pain
  • Abstract The case reported is of a 47-year-old man with an undetected ferromagnetic metallic intraocular foreign body in the right eye who underwent elective MR examinations for chronic neck and low back pain.[ncbi.nlm.nih.gov]
Red Eye
  • Patients usually will show a red eye and a recent history of trauma. Patients are vulnerable to more bleeding three to five days post injury.[medical-dictionary.thefreedictionary.com]
  • Surgery may be required in those who have: Corneal staining Uncontrolled increased intraocular pressures Grade 4 hyphema that persists for 5 days Large clots persisting 10days Tags: air bag eye pain Eye trauma Facial Trauma hyphema red eye Sean M.[pedemmorsels.com]
  • My face is bruised and I have a black and red eye . This morning I noticed a bit of red inside my right eye just on the white under my pupils. I already saw my Dr. and had a CT scan of my face.[emedicinehealth.com]
  • A red eye is one thing, but when you see blood actually trapped inside the front of the eye, we're onto something much more serious.[eyedolatryblog.com]

Workup

A preliminary physical examination along with complete medical history would be gathered. Information about trauma or injury to the eye is necessary, to understand the etiology behind development of hyphema. The following tests would be done to diagnose the condition:

  • Eye examination: An eye examination to study the extent of vision impairment would be required, followed by slit lamp test for detailed examination of the eyes. In order to measure the intraocular pressure, tonometry is indicated. The eyes would further be examined by dilating the pupils to check for cataract, retinal detachment or hemorrhage from other parts of the eye.
  • Imaging: Imaging studies such as CT scan would be necessary if there are signs of trauma. This would indicate fracture of the orbit. B scan is also indicated in order to rule out the presence of any foreign body or tumor that is causing the bleeding. These are required when thorough examination of the eye cannot be done [7].
  • Fluorescein angiogram: This is rarely required, and is indicated in cases, when iris neovascularization is thought to be the cause behind hemorrhage.
  • Gonioscopy: Examining the angle structures of the eye is extremely important to evaluate the extent of blunt trauma that has caused hyphema to set in. The test can however be done after the 5-day critical period has elapsed.
Estrogen Decreased
  • The action of aminobenzoic acid involves inhibition of fibrinolysis, and estrogens decrease antithrombin activity, both of which result in delays of clot resorption ( Westlund 1982 ).[doi.org]

Treatment

Treating hyphema is focused on clearing off the accumulated blood, arresting bleeding and decreasing the intraocular pressure. Individuals are advised bed rest for several days. The eyes are protected with help of shield and the head is kept at an elevated level. For alleviating the pain and inflammation, steroidal and dilating eye drops are prescribed [8].

Individuals are advised against consumption of any kind of drug that contains aspirin or ibuprofen. This is because; the antiplatelet action of aspirin can significantly increase the risk of recurrent bleeding in patients with traumatic hyphema [9].

Patients with sickle cell anemia, who have developed hyphema as a secondary condition, are susceptible to develop various complications such as irreversible damage to the optic nerve and glaucoma when the intraocular pressure remains high for long duration. In addition, affected individuals are also at risk of several complications such as impaired vision and recurrent bleeding.

Surgery is the last resort and it is employed when other conservative approach fail to clear off the blood.

Several studies have postulated the advantage of systemic aminocaproic acid for preventing recurrent hemorrhage. Aminocaproic acid has an antifibrinolytic property which is useful for prevention of secondary hemorrhage in other areas of body as well [10].

Prognosis

Prognosis of the condition greatly depends on the underlying etiology. The nature and severity of the injury will have a significant impact on the vision of the individual. If hyphema has occurred due to sickle cell anemia, individuals would have to be closely monitored. Those with diabetes will require laser treatment to correct the condition. Severe loss in vision can occur in affected individuals [6].

Etiology

Blunt injury due to physical trauma through a deliberate punch in the eye is the major factor. In addition, certain underlying disease condition can lead to onset of hyphema in children. These include, advanced stage of diabetes and blood disorders like sickle cell anemia and hemophilia; in such cases, children seldom experience any signs. Abnormalities concerning the blood vessels, eye infections and iris inflammation also significantly contribute to onset of hyphema. Individuals who have used lens implants can also develop bleeding in the eye’s anterior chamber [3].

Epidemiology

The incidence of hyphema has been estimated to be 17 to 20 per 100,000 individuals each year in the US. Individuals of all age groups can develop the condition [4].

Sex distribution
Age distribution

Pathophysiology

Eyes are a sensitive part of the body. Any injury or trauma to the eyes can be a matter of serious concern. Such factors can cause bleeding in the eye’s anterior chamber which in turn can lead to significant elevation in the intraocular pressure. The bleeding occurs when the blood vessels in the iris get disrupted. This can be a sign of ocular contusion which is characterized by swelling in the cornea as well as retina, iris rupture and a dislocated lens. In instances, when the surrounding tissues of the eye suffer the impact, there may be signs of lid laceration, orbital bone fractures accompanied by orbital hemorrhage [5].

Prevention

Eye injuries can be prevented by wearing protective eye wear while playing sports such as basketball or racquetball. Individuals should seek immediate medical intervention after suffering an eye injury.

Summary

Hyphema is a painful condition, majorly caused due to trauma or blunt injury [1]. The disorder can signal onset of ocular contusion. Prompt medical intervention is necessary for preventing secondary complications from setting in. Individuals are advised to make use of protective eyewear while playing sports to prevent such kinds of injuries [2].

Patient Information

Definition: Hyphema is defined as accumulation of blood in the front portion of the eye. A reddish tinge may be visible in the eyes in case of small hyphema. However, when there is total hyphema, pool of blood may be noticed.

Cause: Blunt trauma is the major cause of hyphema. In addition, underlying disease conditions such as sickle cell anemia and diabetes can also favor development of hyphema.

Symptoms: Due to development of hyphema, the vision can get blurred and eyes become sensitive to light. This may be accompanied by pain and inflammation. Blood pool may be visible to the eye if total hyphema has occurred.

Diagnosis: Preliminary physical examination of the eye will be done to understand the extent of hyphema that has developed. Various tests would be necessary to rule out underlying disease conditions or presence of infections or tumors as the cause may be. In many cases, CT scan or B scan would also be required.

Treatment: Treatment involves complete bed rest for couple of days until the accumulated blood has cleared off. The head is kept at an elevated level and eyes are protected by a shield. Steroidal eye drops are administered for reducing pain and inflammation. Surgery is the last resort and it is employed when treatment approaches fail.

References

Article

  1. Edwards WC, Layden WE.Traumatic hyphema.A report of 184 consecutive cases. Am J Ophthalmol. Jan 1973;75(1):110-6.
  2. Kent JS, Eidsness RB, Colleaux KM, et al. Indoor soccer-related eye injuries: should eye protection be mandatory?. Can J Ophthalmol. Aug 2007;42(4):605-8.
  3. Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral MaxillofacSurg 2001; 59:1462.
  4. Soohoo JR, Davies BW, Braverman RS, Enzenauer RW, McCourt EA. Pediatric traumatic hyphema: a review of 138 consecutive cases. J AAPOS. Nov 8 2013
  5. Hoeh H, Vold SD, Ahmed IK, Anton A, Rau M, Singh K. Initial Clinical Experience With the CyPass Micro-Stent: Safety and Surgical Outcomes of a Novel SupraciliaryMicrostent. J Glaucoma. Oct 9 2014
  6. Shiuey Y, Lucarelli MJ. Traumatic hyphema: outcomes of outpatient management. Ophthalmology 1998; 105:851.
  7. Arey ML, Mootha VV, Whittemore AR, et al. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology 2007; 114:1448.
  8. Yasuna E. Management of traumatic hyphema. Arch Ophthalmol. Mar 1974;91(3):190-1.
  9. Crawford JS, Lewandowski RL, Chan W. The effect of aspirin on rebleeding in traumatic hyphema. Am J Ophthalmol. Sep 1975;80(3 Pt 2):543-5.
  10. Kutner B, Fourman S, Brein K, et al. Aminocaproic acid reduces the risk of secondary hemorrhage in patients with traumatic hyphema. Arch Ophthalmol. Feb 1987;105(2):206-8.

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Last updated: 2019-07-11 22:51