High Yield Topics

Hyphema

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Ovid: 5-Minute Sports Medicine Consult, The


Hyphema
Jorge O. Rodriguez
Adrian Lavina
Basics
Blood in the anterior chamber of the eye
Description
Traumatic hyphema grading:
  • Microhyphema:
    • Circulating RBCs seen by slit lamp exam only
  • Grade I:
    • <33% anterior chamber filling
  • Grade II
    • 33–50% anterior chamber filling
  • Grade III
    • >50% anterior chamber filling
  • Grade IV
    • 100% anterior chamber filling (often referred to as a blackball or 8-ball hyphema)
Epidemiology
  • Blunt or lacerating trauma (projectile or punch)
  • During or after intraocular surgery
  • Spontaneously secondary to neovascularization, neoplasm, uveitis, vascular anomalies of the iris
  • Use of substances that alter platelet or thrombin function
  • Bleeding disorders
Incidence
  • Annual incidence of traumatic hyphema: 12/100,000 (1)
  • Males 3–5 times > Females
  • 77% occur in people >30 yrs, with peak incidence between 10 and 20 yrs of age (1)
Risk Factors
Spontaneous hyphema:
  • Diabetes mellitus
  • Iris melanoma, retinoblastoma, other eye tumors
  • Juvenile xanthogranuloma
  • Clotting disorders
  • Anticoagulants or medications that inhibit platelet function
  • Uveitis
  • Iris neovascularization due to retinal or ocular ischemia
  • Scar formation (cicatrix)
  • Uveitis, glaucoma, hyphema syndrome
General Prevention
  • Protective eyewear should be worn during any high-risk sport such as racquetball or ice hockey.
  • One-eyed athletes should wear eye protection during sports where there is any risk of eye injury.
Etiology
  • Blunt trauma:
    • Bleeding results from tears in the vessels of the ciliary body, iris, and other anterior segment structures
  • Elevated intraocular pressure:
    • Results from RBCs obstructing outflow through trabecular meshwork
    • Prolonged intraocular hypertension results in optic nerve atrophy
    • Secondary glaucoma
  • Rebleeding:
    • Secondary hemorrhage occurs 2–5 days after initial injury:
      • Predisposing factors include: Initial hyphema Grade II or greater, high intraocular pressure (>22 mm Hg), pediatric age group, sickle hemoglobinopathy, African American race, with and without hemoglobinopathy. It is more common in African Americans both with and without sickle cell disease.
      • Systemic bleeding dyscrasia
      • Antiplatelet and anticoagulant medications
    • Predisposes to increased intraocular pressure, secondary glaucoma, corneal blood staining with resultant risk of permanent vision loss
  • Ocular hypotony
  • Penetrating trauma
  • Spontaneous hyphema
Commonly Associated Conditions
  • Corneal abrasion
  • Scleral rupture
  • Intraocular foreign body
  • Perforation
  • Orbital fracture
  • Iridodialysis
  • Recurrent erosion syndrome
Diagnosis
History
  • May accompany multiple trauma or serious head injury
  • Often associated with open globe, posterior segment injury, orbital fracture
  • Patients with sickle cell disease/trait, bleeding tendencies are at high risk for poor visual outcome.
  • If mechanism does not match degree of injury, evaluate for child abuse, diabetes mellitus, clotting disorder, tumors.
Physical Exam
Acute exam (2):
  • Sports-related ocular trauma evaluated on site
  • Obtain adequate history.
  • Best corrected visual acuity is checked with an eye chart if possible.
  • Check confrontation visual fields.
  • Examine pupils.
  • Penlight exam of the anterior chamber
  • Ocular motility
  • External exam looking for orbital injury
  • Funduscopic exam if possible
  • Topical anesthetic may be used to facilitate exam.
  • Eversion of upper and lower eyelids: Identify foreign bodies under tarsal plate.
  • If suspect globe rupture, place protective shield over affected eye, make NPO, refer immediately.
  • Appears as a layering of RBCs in the anterior chamber
  • Physical findings associated with traumatic hyphema:
    • Photophobia
    • Decreased visual acuity
    • Anisocoria
    • Elevated intraocular pressure
Diagnostic Tests & Interpretation
Lab
  • Sickle cell rapid preparation and HgB electrophoresis
  • CBC, prothrombin time, partial thromboplastin time, international normalized ratio to screen for bleeding dyscrasias
Imaging
  • Orbital series: If history and physical suggests fracture
  • B scan US if posterior segment exam limited by a large hyphema
  • Orbital CT scan if concern for globe rupture, intraocular foreign body, orbital fracture
Diagnostic Procedures/Surgery
  • A fluorescein angiogram is not usually indicated in the setting of a hyphema. Once there is an adequate view to take photos of the retina, and if a retinal problem was suspected (such as an arterial occlusion, a choroidal rupture, or contusion necrosis), an angiogram should be done.
  • A gonioscopy puts pressure on the eye and is contraindicated with an acute hyphema.
  • Once the blood is completely resolved, probably around 6 wks after injury, gonioscopy is performed to check for angle recession (trauma to the angle) to determine whether there is increased risk for glaucoma. Gonioscopy can precipitate rebleeding if done too early before the hyphema has resolved.

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Differential Diagnosis
  • Hemolytic glaucoma
  • Ghost cell glaucoma
  • Iris injury
  • Ruptured globe injury
Treatment
Pre-Hospital
  • Place rigid eye shield to protect the eye.
  • Minimize mobility of the patient.
  • Head of transport bed elevated 30–45 degrees so blood will tend to settle inferiorly
  • Do not give any NSAIDs.
  • Keep NPO in case surgery is required.
ED Treatment
  • Assess and treat life-threatening injuries.
  • Assess carefully for ocular perforation (open globe)
  • Avoid succinylcholine if rapid sequence intubation is required and globe rupture suspected.
  • Treat any underlying bleeding dyscrasias.
  • Treat emesis and pain to prevent sudden intraocular hypertension with extrusion of ocular contents.
  • Elevate head of bead to 30–45 degrees and place an eye shield over the affected eye.
  • Instill cyclopentolate, scopolamine, or 1% atropine to dilate the pupil for exam and pain relief after visual acuity has been assessed. If an ophthalmologist is available, they should evaluate the patient prior to pupillary dilatation.
  • Control any ocular hypertension.
  • Provide additional pain control with proparacaine or tetracaine ophthalmic, oxycodone with acetaminophen, morphine, fentanyl
  • Do not give NSAIDs due to the platelet-inhibiting properties.
Medication
  • Proparacaine will facilitate examination of the patient with hyphema if they have pain.
  • Fluorescein dye will help detect a corneal abrasion.
  • In terms of controlling intraocular pressure (IOP), take the IOP and treat as described in “Treatment” section.
Additional Treatment
  • Wear eye shield and restrict activity for 1 wk or until hyphema resolves.
  • Use cycloplegic eye drops: Atropine 1% b.i.d.–t.i.d. (patients without narrow angle glaucoma) (3)[B]:
    • May prevent formation of posterior synechiae
    • Decreases pain from ciliary spasm
  • Topical corticosteroid eye drops (prednisolone acetate 1% q.i.d.) for traumatic hyphema preferred over systemic (3)[C]
  • Traumatic hyphema and intraocular hypertension require medication to decrease intraocular pressure (3)[C]:
    • Use topical beta-adrenergic blocker eye drops.
    • Use topical carbonic anhydrase inhibitor (CAI), such as dorzolamide if sickle cell hemoglobinopathy has been ruled out. In sickle cell, CAIs may cause increased sickling in anterior chamber due to increased ascorbic acid levels in anterior chamber.
    • Use acetazolamide 250 mg PO q.i.d. if necessary as long as sickle cell hemoglobinopathy has been ruled out.
  • It is a consideration to give systemic or topical antifibrinolytic therapy (aminocaproic acid) for patients with traumatic hyphema who are at low risk for thrombotic complications to reduce occurrence of secondary hemorrhage, and for patients who have already rebled (3)[B].
  • Indications for surgical intervention after hyphema:
    • Intraocular pressure ≥50 mm Hg for 5 days
    • Intraocular pressure ≥35 mm Hg for 7 days
    • Total hyphema unresolved for 9 days
    • Microscopic corneal blood staining
  • Because of high incidence of late complications with hyphemas, referral to an ophthalmologist for follow-up is recommended.
  • Outpatient follow-up is usually adequate, but close follow-up is necessary.
  • After resolution of hyphema, complete eye exam by an ophthalmologist with gonioscopy (contact lens exam of angle) and ophthalmoscopy with scleral depression is recommended.
Referral
  • Any hyphema should be referred for ophthalmologic follow-up.
  • Sickle cell disease/trait, bleeding dyscrasia, concern for open globe injury necessitate urgent referral.
Surgery/Other Procedures
  • 5% require surgery.
  • Surgical clot evacuation (3)[C]:
    • Large persistent hyphemas (Grade III or greater for more than 10 days)
    • Early corneal blood staining
    • Uncontrolled intraocular pressure despite maximal medical therapy
In-Patient Considerations
Inpatient management is recommended for (3)[C]:
  • Bleeding dyscrasias or sickle hemoglobinopathy
  • Other ocular injuries requiring hospital care
  • Suspected child abuse
  • Active young children
  • Intraocular hypertension on initial exam
  • Delayed presentation
  • Large hyphemas (Grade III or IV)
Discharge Criteria
Grade I hyphemas and microhyphemas can be managed as an outpatient if intraocular pressure is stable.
Ongoing Care
Patient Education
  • Review symptoms of rebleeding or elevated intraocular pressure (sudden decreased vision and pain).
  • Review symptoms of retinal detachment (flashes, floaters, shade descending over vision).
  • Provide medications and medication schedule prior to discharge to improve adherence.
  • Minimize activity.
Prognosis
  • Final visual acuity depends on size of hyphema and related complications.
  • Secondary hemorrhages usually result in hyphemas that are larger than the initial injury.
  • Grade I resolve in 4–5 days.
  • A final vision of 20/50 or worse is seen in 10% of patients with Grade I and in 50–75% with Grade III or IV.
  • 14% of hyphema patients have poor visual outcomes as a result of associated sequelae (vitreous hemorrhage, retinal detachment, ocular rupture).
  • Blunt eye injury and hyphema increase risk of traumatic glaucoma.
References
1. Andreoli CM. Traumatic hyphema: epidemiology, anatomy, and pathophysiology. Retrieved June 22, 2009 from www.uptodate.com, 2009.
2. Rodriguez JO, Lavina AM, Agarwal A. Prevention and treatment of common eye injuries in sports. Am Fam Physician. 2003;67:1481–1488.
3. Andreoli CM. Traumatic hyphema: clinical features and management. Retrieved June 22, 2009 from www.uptodate.com, 2009.
Additional Reading
Ashaye AO. Traumatic hyphaema: a report of 472 consecutive cases. BMC Ophthalmol. 2008;8:24.
Irak-Dersu I. Glaucoma, hyphema. Retrieved November 23, 2009 from http://emedicine.medscape.com/, 2007.
Walton W, Von Hagen S, Grigorian R, et al. Management of traumatic hyphema. Surv Ophthalmol. 2002;47:297–334.
Weber TS. Training room management of eye conditions. Clin Sports Med. 2005;24:681–693, x.
Codes
ICD9
364.41 Hyphema of iris and ciliary body
Clinical Pearls
  • Protective devices (2):
    • The American Society for Testing and Materials has established performance standards for selected eyewear that are most appropriate for sports with a risk of ocular injury.
  • Return to play (2):
    • The injured eye should feel comfortable with adequate return of vision.
    • Eye protectors must be worn for sports at high risk for ocular injury.


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