Hyphema Evacuation

Indications

First sign of corneal stromal blood staining

Total or near-total hyphemas that do not resolve by day 5

Sickle cell trait or disease patients with intraocular pressure (IOP) greater than 25 for more than 24 hours

Progressively worsening visual acuity

Persistent blood clot in angle for longer than 10 days

Increase in IOP despite maximum medical therapy (IOP greater than 50 mm Hg for 5 days or greater than 35 mm Hg for 7 days)

Preoperative Procedure

1. Perform a complete ocular examination to rule out a ruptured globe.

2. Document the size (percentage of anterior chamber) of the hyphema, as well as any other anterior segment abnormalities.

3. Measure the IOP and perform a dilated fundus exam (avoid scleral depression).

4. B-scan ultrasonography, computerized tomography magnetic resonance imaging, and ultrasound biomicroscopy may be useful in assessing the anterior segment and posterior segment.

5. Patients of African and Mediterranean descent must be screened for sickle cell trait or sickle cell disease (Sickle-dex prep; hemoglobin electrophoresis if necessary).

Supportive Treatment

1. Shield the affected eye with metal or plastic at all times.

2. Confine patient to bed rest, or to very limited activity.

3. Elevate head 30 degrees while resting and sleeping.

4. Prescribe mild analgesia (e.g., acetaminophen).

5. Avoid aspirin-containing products, nonsteroidal anti-inflammatory agents, or anticoagulants.

Medical Treatment

1. Cycloplegia (e.g., Atropine 1% drops 2–3 times per day).

2. Steroid drops (e.g., prednisolone acetate 1% 4–8 times per day), based on inflammation.

3. Management of IOP.

a. β-blockers should be used if IOP > 30 mm Hg (lower threshold for sickle cell and previous glaucoma patients).

b. Add α-agonist or topical carbonic anhydrase inhibitor, or both if needed.

c. Consider oral acetazolamide or intravenous mannitol if drops are unsuccessful.

Note: Sickle cell patients may use β-blockers, but all other medicines must be used with caution. Topical and systemic carbonic anhydrase inhibitors may induce sickling. α-agonists may affect iris vessels. Prostaglandin-analogs and miotics may promote inflammation.

4. In hospitalized patients, oral or topical aminocaproic acid may be administered to reduce rebleeding, if not medically contraindicated.