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Hyphema, Sign, Symptoms and it's management

HyphemaThe blood in the front of the anterior chamber of the eye is known as hyphema.

Causes:

  • Blunt trauma
  • Intraocular surgery
  • Lacerating trauma,
  • Penetrating & perforating injury
  • It also occurs spontaneously without any trauma, usually neovascularization, a tumor of the eye (Retinoblastoma), uveitis or vascular anomalies.
  • Using of medicine that causes thinning of blood such as aspirin, ibuprofen etc.

Symptoms:

  • Pain
  • Photophobia
  • Blurred vision
  • Watering

Sign:

  • Blood or clot in the anterior chamber, usually visible without slit lamp.
  • Sometimes total hyphema(100%) may be present.

Pathophysiology:

There are 2 suggested mechanism of hyphema formation
  • The direct contusive force causes mechanical tearing of blood vasculature of iris and or angle.
  • Concussive trauma creates rapidly rising intravascular pressure within the vessels resulting in rupture of vessels.
Blood in the anterior chamber is not by itself necessarily harmful. However, if quantities are sufficient it may obstruct the outflow of aqueous humor, resulting in glaucoma
Blood in Eye

Examination/Workup

1. History

  • Mechanism of injury?
  • Uses of medications such as aspirin, ibuprofen, NSAIDs with anticoagulant properties.
  • H/O sickle cell disease?

2. Ocular Examinations:

  • Visual acuity
  • IOP
  • Slit lamp examinations
  • Hyphema height, location
  • Cornea (to rule out perforation)
  • Sclera (to rule out rupture globe)
  • Anterior chamber
  • Lens, Vitreous, Retina
  •  B-scan(gently) if fundus view is poor due to entire A/C filled with blood.
  • If suspected orbital fracture or IOFB consider CT scan of orbit.

 Grading of Hyphema, Blood in Eye  

Treatment:

Main goals of treatment

  • To decrease the risk of re-bleeding within the eye.
  • To decrease the risk of corneal blood staining.
  • To decrease the risk of atrophy of optic nerve.
  • To prevent Peripheral anterior synechia.  
  1. Hospitalization

  2. Strictly bed rest, Elevate the head to allow blood to settle.

  3. Eye Shield at all the time.

  4. Dilating Drop:

  • Atropine 1% BD, it increases comfort from traumatizing iris as well as reduce bleeding.
  • It prevents from posterior and anterior synechiae.

       5. Steroid

  • Prednisolone acetate 1% (1 hourly- QID)
  • It helps to reduce inflammations.
  • If any suggestion of iritis, lens capsule rupture any fibrin is seen in the anterior chamber it is indicated. Tapper Steroid when sign and symptoms resolve to reduce steroid-induced glaucoma.

If Intra Ocular Pressure is increased

  • Increased IOP especially seen after trauma, may be transient, secondary to acute mechanical plugging of the Trabecular Meshwork.
  • Start with beta blockers (Timolol 0.5%, Betaxolol). 
  • IF IOP is still high-
  • Add topical alpha agonist (briminodine 0.15%), TDS, it is contraindicated in children.
  • Add Carbonic anhydrase inhibitor Gtt. Dorzolamide2% 1drop*TDS
  • If topical therapy did not control IOP then start Tab Acetazolamide ( DIAMOX) 500mg* BD
  • Or Start IV MANITOL 1-2mg/kg

Indications for surgical evaluation of hyphema.

  • Corneal stromal blood staining
  • Significant visual detortion
  • Hyphema that doesn't decrease to ≤50% by 8 days (to prevent PAS)
  • Iop ≥ 60mmofhg for  ≥ 48 hours, despite maximal medical therapy (to prevent optic atrophy)
  • Iop  ≥ 25mmof hg with total hyphema for  ≥  5days (to prevent corneal stromal blood staining)
  • Iop 24 mm of Hg for ≥  24hours(or any transient increase in IOP  ≥ 30 mm of Hg) in sickle disease patient.
  • Consider early surgical intervention for children at risk of amblyopia.

Note:

Gonio is contraindicated because it increases the risk of rebleeding, perform it after the event has resolved and risk of rebleeding is passed.

Complications:

  • Increased IOP
  • Peripheral anterior synechiae
  • Optic atrophy
  • Corneal stromal blood staining
  • Rebleeding
  • Impaired accommodation.

Prevention:

  • Hyphema can occur with any trauma to the eye, wear protective eyewear when playing and doing outwork.

Disclaimer: Please Consult with Ophthalmologist for treatment. We do not suggest self medication with reference to our site. 

References:-

  1. Wills eye manual, 6th edition
  2. A.K Khurana's comprehensive ophthalmology
  3. www.ophthobook.com 

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