[Emergency] Atlas of Hyphema

These are pictures of Hyphema. This is a part in OPHTHALMIC TRAUMA of the Atlas of Emergency Medicine book

Clinical Summary

Injury to the anterior chamber that disrupts the vasculature supporting the iris or ciliary body results in a hyphema. The blood tends to layer with time, and if left undisturbed, gravity will form a visible meniscus. Symptoms can include pain, photophobia, and possibly blurred vision secondary to obstructing blood cells. Nausea and vomiting may signal a rise in intraocular pressure (glaucoma) caused by blood cells clogging the trabecular meshwork.

Management and Disposition

Prevention of further hemorrhage is the foremost treatment goal. Most rebleeding occurs within the first 72 hours and is usually more extensive than the initial event. Keep the patient at rest in the supine position with the head elevated slightly. Use a hard eye shield to prevent further trauma from manipulation. Avoid oral or parenteral pain medication and sedatives with antiplatelet activity such as

NSAIDs. Use antiemetics if the patient has nausea. Further treatment at the discretion of specialty consultants may include topical and oral steroids, antifibrinolytics such as aminocaproic acid, or surgery. Measure intraocular pressure (IOP) unless there is a suspicion of penetrating injury to the globe. Treat elevated IOP with appropriate agents, including topical β-blockers, pilocarpine, and, if needed, osmotic agents (mannitol, sorbitol) and acetazolamide. Ophthalmologic consultation is warranted to determine local admission practices. 

Pearls

1. Instruct patients specifically not to read or watch television, as these activities result in greater than usual ocular activity.

2. Rebleeding may occur in 10% to 20% of patients, most commonly in the first 2 to 5 days when the blood clots start to retract.

3. An “eight-ball” or total hyphema often leads to elevated IOP and corneal bloodstaining, and typically requires surgical evacuation. 

4. Patients with sickle cell and other hemoglobinopathies are at risk for sickling of blood inside the anterior chamber. This can cause a rise in IOP caused by obstruction of the trabecular meshwork even if only a small hyphema is present. 

5. An abnormally low IOP should prompt consideration for presence of penetrating globe injury.

6. Evaluate supine trauma patients for slight differences in iris color to determine the presence of a hyphema. 

FIGURE 4.12 ■ Hyphema. This hyphema is just beginning to
layer out, reflecting its acute nature.  

FIGURE 4.13. ■ Hyphema. This hyphema has completely layered
out in the anterior chamber.  

FIGURE 4.14 ■ “Eight-Ball” Hyphema. This hyphema completely
fills the anterior chamber. 

FIGURE 4.15 ■ Hyphema. A small hyphema (about 5%) in a patient with sickle cell disease. 

REFERENCES

The Atlas of Emergency Medicine, Fourth Edition, 2016.