This document discusses hyphema, which is blood in the anterior chamber of the eye. It defines hyphema and lists its potential causes such as trauma, medical conditions, and surgeries/medications. The document outlines methods for grading hyphema based on the amount of blood in the anterior chamber. It also discusses the clinical features, workup, potential complications like increased eye pressure, and treatment approaches like medical management with anti-inflammatory drugs and surgery if needed to prevent complications. The prognosis depends on factors like the severity of hyphema and any associated eye damage.
5. PATHOGENESIS
Mechanism
Direct contusive force that causes antero-
posterior compression and equatorial expansion
leads to mechanical tearing of blood vasculature of
iris, ciliary body and TM.
Concussive force creating rapidly rising IOP with
in the vessels resulting in rupture of vessels
Penetrating injury leads to hyphema by
damaging the blood vessels and due to hypotony
6. GRADING
Grade 1: < 1/3th of AC
Grade 2: 1/3th
-1/2 of AC
Grade 3: > ½ of AC
Grade 4: Total
7. CLINICAL FEATURES
Blurring of vision
Photophobia
Pain
Headache
Blood or clot or both in the AC
Mean duration of elevated IOP is 6 days
Duration in uncomplicated hyphema is 5-6 days
8. WORK-UP
History
Mechanism of injury
Time of injury
H/o medication (Aspirin, Warfarin)
H/o Sickle cell disease
H/o Coagulopathy – bleeding gums, epistaxis
Examination
Rule out any rupture globe or penetrating injuries
Visual acuity
IOP
Slit lamp
B scan (gently)
CT scan - suspected orbital floor # or IOFB
9. COMPLICATIONS
Increased IOP:
Occlusion by clot, inflammatory cells, erythrocytic debris
Pupillary block due collar button shaped clot
Peripharal anterior synechiae: if hyphema > 01 week
Optic atrophy:
IOP > 50 mmHg for 5 days or >35 mmHg for 7 days.
Contusion to the optic nerve
Secondary to damage to short posterior ciliary arteries.
Sickle cell disease even at normal IOP
Secondary haemorrhage (rebleed): usually occurs after
day 4
Increase in size of hyphema
Layer of fresh RBCs over previous clot
Change of colour from dark red to bright red.
10. COMPLICATIONS
Corneal blood staining:
Factors which influence corneal blood staining:
Rebleeding
Prolonged clot duration
Sustained increase in IOP
Corneal endothelial dysfunction
Two main risk factors of corneal blood staining:
IOP >25 mm of Hg
> 6 days duration
Earliest signs:
straw coloured discoloration of deep stroma
presence of tiny yellow granules in posterior
1/3rd
of the cornea
11. MANAGEMENT
Quick absorption of blood
Prevention of complications
Avoidance of recurrence
Discontinuation of anti coagulation therapy
Limiting activities
Rest in semi upright position and head end elevation
Patching
12. OUTPATIENT MANAGEMENT
Walton et al:
no associated injury
hyphema < ½ of AC volume
satisfactory IOP
no blood dyscrasia
safe home environment
good patient compliance
good follow up
no time delay at presentation
13. MEDICAL MANAGEMENT
Anti inflammatory drugs - NSAIDs
Cycloplegics
Topical, oral and systemic anti glaucoma drugs
Steroids
Anti fibrinolytic drugs - tranexamic acid, TPA,
aminocaproic acid
Laser photocoagulation of bleeding points by
goino prism
14. Anti fibrinolytic agents: epsilon amino caproic acid
(EACA) and Tranexamic acid are used to prevent
rebleed
EACA (amicar) binds to lysine molecules in the
clot via lysine binding site and inhibits fibrin clot
digestion. Its dose is 100mg/kg every 4 hours to a
maximum dose of 30g/day by mouth for 5 days.
Tranexamic acid also has similar mechanism.
The results of various studies indicate that both
amicar and tranexamic acid have beneficial effect
on rate of secondary haemorrhage but none of
them had improved the final visual outcome.
15. Corticosteroids:
Stabilizes the blood-ocular barrier
Directly inhibits fibrinolysis
Decrease incidence of secondary haemorrhage.
Prednisolone (0.6 mg/kg) is effective in reducing
the incidence of rebleed
Statistical analysis indicates that coticosteroids
decreases the incidence of rebleeding without
having any effect on the long term visual outcome.
Cycloplegics:
Studies advocate use of Cycloplegics as they
relieve ciliary spasm and prevents formation of
PAS
16. SURGICAL MANAGEMENT
Indications (Walton et al):
Microscopic corneal blood staining
IOP > 60 mm of Hg for 2 days
IOP > 50 mm of Hg for >4 days
IOP > 35 mm of Hg for 7 days
Pre-existing glaucomatous optic atrophy
Risk of corneal blood staining (e.g 4 days after the
onset of glaucoma, > ½ - total hyphema with IOP >
25mmHg > 6 days
Risk of synechiae formation (e.g > 50% hyphema for
> 8 days
Visual obstruction in children at risk of amblyopia
Sickle cell disease if IOP >25 mm of Hg for >24 hours
or spikes repeatedly >30 mm of Hg
17. SURGICAL MANAGEMENT
Simple paracentesis - allow the clot to retract
Irrigation and aspiration
Through a large limbal incision: manual expression,
cryoextraction, ultrasonic emulsification
Clot expression and limbal delivery is usually
advocated 4 to 7 days after the initial injury, when clot
consolidation and retraction is at its peak.
Clot irrigation with trabeculectomy is reserved for
total hyphema
18. FOLLOW-UP
Hospitalised patient - Daily V/A, IOP, Slit lamp exam
After discharge - next follow up after 2-3 days
1 - 2 weeks as per severity
After 4 weeks - gonioscopy and fundus exam
19. PROGNOSIS
Determinants:
Amount of associated damage to other ocular
structures like choroidal rupture, macular scarring
Secondary hemorrahge (rebleed)
Complications of Glaucoma, corneal blood
staining or optic atrophy
Recovery of V/A is good in approx 75% of patients:
Hyphema <1/3 of AC -- V/A 6/12 or better in
80% cases
Hyphema >1/2 - 2/3 of AC -- V/A 6/12 or better
in 60% cases
Hyphema Grade IV -- V/A 6/12 or better in 35%
cases