As with all forms of pediatric trauma, the precise occurrence that led to the hyphema may be difficult to determine. The possibility of abuse must be considered, as must the possibility of a nontraumatic etiology: retinoblastoma, juvenile xanthogranuloma of the iris, and bleeding diathesis resulting from leukemia or other blood dyscrasia are relatively rare but important causes of spontaneous hyphema during the early years of life. When the findings are suspicious and the iris and fundus cannot be adequately seen, ultrasonography or magnetic resonance imaging should be performed to rule out intraocular tumor. If a bleeding disorder is suspected, a complete blood count and coagulation studies should be performed.
Intraocular pressure (IOP), an important factor in therapeutic decision making for patients with traumatic hyphema, is often difficult to monitor in the pediatric patient. The risks of inaccurate measurements and of further traumatizing the injured eye may outweigh the potential value of obtaining measurements in uncooperative children. With small hyphemas (Fig 27-2), concern about pressure is greatest in patients with sickle cell trait or disease. Sickling may develop in the anterior chamber, elevating IOP and retarding resorption of blood, or in the retinal circulation, causing vascular occlusion. All African American children with traumatic hyphema require sickle cell screening to evaluate for these conditions.
Figure 27-2 Small hyphema. Note the layering of blood inferiorly.
(Courtesy of Edward L. Raab, MD.)
As in adults, medical management of hyphema in children remains controversial. Care must be taken to minimize the risk of rebleeding, which usually occurs between 3 and 7 days postinjury as a result of clot lysis and retraction. Outpatient management with activity restriction and close follow-up is generally accepted. However, if parental cooperation is questionable or if the patient has sickle trait, hospitalization for several days after injury, when the risk of rebleeding is greatest, remains justifiable. Many ophthalmologists routinely use cycloplegic and corticosteroid drops to facilitate fundus examination, improve comfort, and reduce the risk of inflammatory complications and rebleeding. The value of these topical agents is unproven, and some clinicians prefer to use them selectively for control of pain or obvious inflammation, or to avoid them altogether to minimize manipulation of the eye. Pressure-lowering medication is appropriate for eyes known or strongly suspected to have elevated IOP. Aspirin-containing compounds and nonsteroidal anti-inflammatory drugs can increase the risk of rebleeding and should be avoided.
Many treatments have been proposed to prevent rebleeding in traumatic hyphema, although none is universally accepted. See Chapter 14 in BCSC Section 8, External Disease and Cornea, for a discussion of treatment considerations for traumatic hyphema.
The difficulty of detecting early corneal blood staining in a child and the risk that staining may cause severe deprivation amblyopia, coupled with the problems of accurately measuring IOP, justify early surgical intervention whenever a total hyphema persists for 4–5 days. In children with sickle cell trait or disease, it may be necessary to perform surgery even earlier if elevated pressures (>25 mm Hg for over 24 hours) occur.
Late glaucoma is a potential complication of traumatic hyphema in children, as in adults, and may occur with no symptoms. Gonioscopy can be performed after the eye has healed and the child is able to cooperate. Annual follow-up should be continued in children with a history of traumatic hyphema, in light of the potential late complications of cataract, retinal detachment, and glaucoma.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.