Hyphema

Definition:  Blood in the anterior chamber (front part) of the eye.  This can be a macrohyphma (grossly detectable) or microhyphema (microscopic-magnification needed to observe)

Signs/Symptoms: 

• Pain

• Photophobia

• Blurred vision

• Generally history of blunt trauma

• Macrohyphema or hyphema: 

  • Grossly visible layering of a blood clot in the front part of the eye

• Total hyphema ("eight ball") 

  • Appears dark almost black. 

• Microhyphema:  

  • Red cells suspended in the aqueous of the eye normally viewed with a slit lamp

  • Difficult to see when viewed with a direct ophthalmoscope

  • May appear hazy 

Causes:  Generally occur with trauma associated with fighting, and sports.  Occasionally spontaneous and can sometimes be seen with diseases like diabetes.  

Differential Diagnosis: 

• History of blunt trauma

• Iris tears

• Laser injuries

• Intraocular injuries secondary to penetrating trauma

Evaluation: 

• Visual acuity

• History:

  • Mechanism of the injury

  • Time or injury

  • Was there loss of vision? 

• Ocular exam:

  • Look for ruptured globe. Most common areas of globe rupture: 

    • At limbus

    • Insertion of intraocular muscles

    • Penetrating injury of the eye (corneal laceration).

  • Look at lids and surrounding structures to be sure there is no other associated trauma (lid laceration, fracture of orbital rim). 

  • Estimate the amount of the hyphema and draw as a pictorial validation. 

  • Measure intraocular pressure if possible(as long as there is no presence of a laceration)

• Screen for sickle cell in black patients or patients or mixed race.  

Treatment: 

• Medvac patients that have globe rupture or penetrating injuries as soon as possible.  

• If unable to Medvac,  maintain moistness with normal saline (NOT WATER) and cover loosely with a sterile gauze.

• Medvac patients with elevated intraocular pressure (over 25), and with sickle cell disease/trait with elevated intraocular pressure.  If unable to Medvac then give topical beta-blocker one drop bid. 

• Discontinue, ASA, or NSAIDs

• Acetaminophen 325mg 2 tablets may be used for pain

• For more severe pain acetaminophen 325mg with ½ gr of codeine.

• Confine to bed rest with bathroom privileges only, no strenuous activity

• If necessary, sedate with mild antihistamine as dyphenhydramine 25mg tid po

• Atropine 1% drops to the affected eye 3 times a day

• Cover eye with a metal or plastic shield to protect eye and for easily observation or a re-bleed.  

Prognosis:  

• Generally good.  

• For microhyphema and small hyphema’s patient should be back to work in 5 days.  

• If trauma is severe, observe patient for the possibility of a traumatic cataract.  

• The most common time for a hyphema re-bleed is on the 3^rd or 4^th day post trauma, but with aggressive bed rest re-bleeds are uncommon.  

• Following the 5^th day the patient should be seen for long term problems associated with anterior segment trauma by an ophthalmologist.    

This section provided by CAPT Robert B. North, Jr., MC, USN

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