Traumatic Hyphema
Evan Silverstein, MD
Traumatic hyphemas in children require both close immediate follow-up and longterm monitoring for secondary glaucoma.1
ETIOLOGY
Obtain a good history of etiology. If not known, keep a broad differential. Have a high suspicion for open globe injuries.
Without known trauma, consider nonaccidental trauma, retinoblastoma, leukemia (or other bleeding diathesis), and juvenile xanthogranuloma.
INITIAL EVALUATION
Examine entire globe and surrounding adnexa. Be on high alert for other injuries including:
Retrobulbar hemorrhage (tight lids, very high IOP, resistance to retropulsion).
Orbital fractures (consider CT scan based on etiology and motility examination to evaluate for muscle entrapment).
Open globe (associated diffuse hemorrhagic chemosis or peaked pupil).
Obtain complete eye examination including visual acuity, IOP, pupil examination (looking specifically for a relative afferent pupillary defect, traumatic mydriasis, and iridodialysis), motility, and anterior and posterior examination.
Measure hyphema in millimeters (if possible). This allows objective tracking of the resolution or worsening of the hyphema.
If no view to the fundus, obtain B-scan to evaluate for retinal detachment.
Additional history: Sickle cell trait or disease (obtain sickle cell prep to screen for sickle cell disease in African American patients of unknown status), hemophilia, von Willebrand disease.
Children with sickle cell disease or trait are at higher risk of elevation of intraocular pressure as a result of obstruction of trabecular meshwork with sickled red blood cells. Oral carbonic anhydrase inhibitors (eg acetazolamide) are contraindicated in these patients.
MEDICAL MANAGEMENT
Protect eye with clear shield at all times until hyphema resolves.
Using a clear shield allows the child to see through the shield, which decreases the risk of amblyopia and also enables the child to report vision changes and the parents to visualize if the hyphema significantly worsens.
Strict bed/chair rest.
Limit physical activity to decrease the risk of rebleed and allow blood to settle out of the visual axis.
Elevate the head and/or head of the bed while sleeping.
Prednisolone acetate 1% topical drops.
Often prescribed four times daily.
Be aware that topical steroids can cause steroid-induced ocular hypertension.
Stop steroids when hyphema is resolved.
Atropine 1% topical drops.
Prescribed daily until hyphema resolves to treat discomfort from ciliary spasm.
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