Diagnosis: Traumatic hyphema
A hyphema refers to a collection of blood in the anterior chamber. Traumatic hyphemas are the most common form of hyphema and are most often caused by blunt trauma. Symptoms include blurry vision and in the setting of trauma, may include photophobia, headache, and pain.
Hyphemas can be associated with a number of complications that patients must be monitored closely for including ocular hypertension and glaucoma, corneal blood staining (see image on right – image credit), corneal blood staining, and rebleeding which typically occurs within the first 5 days when the initial clot on the violated blood vessel retracts and lyses.
Ocular Hypertension and glaucoma risk is higher in patients with sickle cell disease or trait as sickled cells can mechanically obstruct the trabecular meshwork, blocking aqueous outflow and clearance of red blood cells. The sickling of cells can also be exacerbated by carbonic anhydrase inhibitors. Therefore it is important to assess for history of sickle cell and consider a Hgb gel electrophoresis prior to initiating any therapy for elevated intraocular pressure with carbonic anhydrase inhibitors.
Other types of hyphema include hyphemas in the setting of neovascularization of the iris, inflammation or infection, iris neoplasms, and iatrogenic hyphemas in the setting of ocular surgery or laser. Vascular anomalies such as those present in juvenile xantogranuloma can also cause hyphema. The image on the left shows a nodular iris juvenile xanthogranuloma (image credit).
Treatment
Management includes topical steroids steroids and cycloplegia which serves to both to mitigate photophobia and mechanically compress the blood vessel causing the hyphema. Blood thinners such as NSAIDs and anticoagulants should be avoided to decrease risk of re-bleeding. Aqueous suppressants are also indicated in cases of ocular hypertension/glaucoma, with avoidance of carbonic anhydrase inhibitors in cases of sickle cell, as discussed above.
Addtionally, elevation of the head of the bed at 30-45 degrees to promote layering of the hyphema and clearing of the visual axis is advised, along with avoidance of rigorous activity. The patient should be closely monitored for clearing of the hyphema, IOP monitoring, rebleeding, and corneal blood staining. Nonclearing hyphema, rebleeding, persistently elevated IOP, and corneal blood staining are all indications for surgical intervention to clear the hyphema. Finally, in cases of rebleeding, use of an inhibitor of fibrinolysis, such as aminocaproic acid, can be considered to prevent lysis of the clot occluding the vessel from which the hyphema originated.
References and Additional Resources:
1. Patel AS, Greenwood MD. Hyphema. Syed ZA (Eds). American Academy of Ophthalmology: EyeWiki. March 2021. Available at: https://eyewiki.aao.org/Hyphema#Surgery.
2. Wagner LH, Xu SC, Swanson A. “Juvenile Xanthogranuloma” Grigorian AP (Eds). American Academy of Ophthalmology: EyeWiki. Jan 2022. Available at: https://eyewiki.aao.org/Juvenile_Xanthogranuloma.
Case 9 Index
Ophtho On Call Case 9 Index
Ophtho On Call Case 9: Introduction
Ophtho On Call Case 9: Additional History & Physical Exam
Ophtho On Call Case 9: Case Continued…