BASICS

DESCRIPTION

Blood in the anterior chamber (segment).

GENERAL PREVENTION

Safety eyewear protection

PATHOPHYSIOLOGY

Bleeding from the structures of the anterior segment of the eye; for example, an iris tear, iridodialysis, or cyclodialysis secondary to trauma and rarely from vascular abnormalities or bleeding diaphyses.

ETIOLOGY

Usually associated with trauma; including intraocular manual and laser surgery.

COMMONLY ASSOCIATED CONDITIONS

• Hematodyscrasias and coagulopathies (pathologic and pharmaceutic)

• Intraocular neoplasm and infections

DIAGNOSIS

HISTORY

• When nonsurgical trauma is suspected, a definitive history of the mechanism should be acquired. This should include the description of the object, its momentum and direction, and the exact location of impact. For example: A fist of a large assailant with a side strike to the brow versus a forceful explosion with sharp shrapnel hitting the globe directly while not wearing spectacles

• Inquire about predisposing factors, such as anticoagulants or conditions that may cause a bleeding diathesis

PHYSICAL EXAM

• Rule out ruptured globe/ intraocular foreign body (IOFB)

• Take baseline examination: Va, IOP, Slit Lamp Exam (SLE), Dilated Fundus Exam (DFE)

• Clotted, layered, or suspended blood in the anterior chamber which is best visualized by slit-lamp examination

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Initial examination and testing is intended to assess the degree of visual compromise, possible additional ocular injury, and establish a baseline to monitor resolution or progression of the hyphema.

• Visual acuity (VA)

• Intraocular pressure (IOP)

• Measurement of clot, layer, or degree of suspended blood to monitor resolution or rebleeds

• Blood studies as indicated

Imaging

Initial approach

If a rupture globe or IOFB is suspected, direct visualization and/or imaging to include ultrasound (careful if there is possibly an open globe) and CT. MRI is contraindicated in cases of possible metallic IOFB’s. Vegetable matter, such as wood, may be difficult to image.

Follow-up & special considerations

Direct at monitoring resolution of hyphema and avoidance of complications such as pressure rise, rebleeds, and corneal staining.

Diagnostic Procedures/Other

• B scan imaging if visualization is poor

• UBM if more detailed imaging of the anatomical angle is needed

Pathological Findings

Clotted, layered, or suspended blood in the anterior chamber, which is best visualized by slit-lamp examination.

TREATMENT

ADDITIONAL TREATMENT

General Measures

Treatment is directed to

• Stabilize the patient

• Stop bleeding

• Stop strenuous physical activity

• Shield eye from further trauma with clear eye shield or safety spectacles. Do not block vision with patches and so on because the patient must be able to assess changes in his/her vision

• Promote healing

• Have the patient remain upright with bed rest at 30 degree angle to have the blood settle and clot. This will help the patient’s visual acuity and promote aqueous fluid drainage. In a pediatric or poorly compliant patient, bed rest may be advisable.

• Decrease inflammation

• A penetrating topical steroid (e.g., prednisolone acetate 1%) 4–8 ×/day. If there is an associated corneal abrasion, use with caution or begin after epithelialization occurs.

• Avoid complications

• Synechiae – keep the eye dilated. This also helps to immobilize the iris, which may be a location of bleeding. Long acting dilation with Atropine 1%, Homatropine 2%, or scopolamine 0.25 % are generally used b.i.d.

• Pressure rise

• This may be delayed and transient as the RBC’s are filtering through the trabecular meshwork. Initiation of treatment should be based on the extent and duration of the pressure rise as well as the patient profile for optic nerve risk factors.

• Appropriate patients should be screened for sickle cell disease/trait (Sickledex test) or other hemoglobinopathies (hemoglobin electrophoresis) because of possible complications from some pharmacologic agents, such as brinzolamide (Azopt) & dorzolamide (Trusopt) topically and systemic diuretics.

• Beta blockers are generally used as an initial agent.

• Alpha antagonists are used with caution because of systemic side effects.

• Oral diuretics if topical methods of antiocular hypertensive therapy are in effective. Avoid agents that may promote sickling in patients at risk.

• Avoid prostaglandin analogs, due to their promotion of intraocular inflammation effects.

• Anterior chamber paracentesis is controversial in hyphema. It requires an extremely cooperative patient. Anterior chamber structures are poorly visible, the procedure may result in a secondary rebleed, and the effects are temporary.

• Aminocaproic acid is seldom used and is usually reserved for hospitalized pediatric patients who have had rebleed episodes.

• Corneal blood staining. A late but gravid complication whereby hemoglobin and iron from lysed RBC’s enters the corneal stroma. Generally a result of a longstanding large hyphema in a hypertensive eye. Patients at risk for this complication should be evaluated for an anterior chamber wash out.

Additional Therapies

• Shield the eye at all times with protective spectacles or eye shield – including when at rest.

• Limit physical activity for 1 week after resolution of the hyphema.

• Keep the head elevated to promote RBC settlement; including 30 degree bed rest

• Antiemetics for nausea and vomiting and stool softeners to prevent Valsalva.

• Avoid aspirin products or NSAIDs as an analgesic because of bleeding tendencies.

SURGERY/OTHER PROCEDURES

If surgical washout of the anterior chamber (AC) is indicted, the patient should be prepared according to intraocular surgery protocols. Irrigation and aspiration of the AC is cautiously performed to evacuate hematologic contents without disrupting ocular structures or tearing clots and causing a rebleed.

IN-PATIENT CONSIDERATIONS

Initial Stabilization

• Rule out ruptured globe/IOFB

• Take baseline examination: Va, IOP, SLE, DFE

• Stabilize IOP if necessary

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

The patient should be observed until there is resolution of the hyphema, cessation of therapy, and the pupils return to normal size and function. Gonioscopy should be performed. Follow-up should be at 6 months initially, then annually for evaluation of angle recession glaucoma.

ADDITIONAL READING

• Ehlers JP, Shah CP. (eds). The Wills Eye Manual, 5th (ed). Lippincott Williams & Wilkins, Philadelphia, 2008:19–23.

CODES

ICD9

364.41 Hyphema of iris and ciliary body

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