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  • YO Need to Know: 5 Pearls for Managing Hyphema

    Photo of Hyphema

    Hyphemas can be graphic to see, especially when blood covers all or part of the iris and pupil. A hyphema must be treated properly, or it can cause permanent vision problems.

    If you come across a patient with a hyphema in the emergency department or while covering the consult service in your hospital, here are some pearls for important evaluation and management to keep in mind. 

    Grading the Hyphema

    Hyphemas can be graded from 0 to IV depending on the extent of blood in the anterior chamber. Grade “0” demonstrates no visible layering with some red blood cells in the anterior chamber (also called a microhyphema), while grade IV demonstrates total filling of the anterior chamber with blood (also called a total hyphema). The higher the grade is for a hyphema, the higher the risk for intraocular pressure elevation. Also, consider measuring the height (in millimeters) of the hyphema at the slit lamp so you can objectively follow its resolution and allow other providers to compare their examination to yours. Even better, take a picture! 

    The exception to this rule is in sickle cell trait or disease, where a hyphema that is small with a lower grade can still confer risk of elevated intraocular pressure. It is worth screening all African American patients with a hyphema for sickle cell trait or disease since sickle cell disease confers greater risk of trabecular meshwork obstruction with defective red blood cells. Sickle cell trait or disease is more common in African American patients, so screening for this is important for all African American patients with hyphema. Additionally, the sickled red blood cells can cause vaso-occlusive sequelae, such as central retinal artery occlusion and ischemic optic neuropathy when intraocular pressure is elevated. 

    The color of a hyphema can vary from red to black depending on the time frame of when the hyphema first emerged. Hyphemas can have a darker or blackened appearance if the blood has clotted. If the anterior chamber is filled with dark red and black blood, it is often called a blackball or “8-ball” hyphema. Blackball hyphemas are more likely to cause pupillary block and secondary angle closure. 

    Possible Complications

    Patients should be monitored closely in the first few days after a hyphema because this is the time frame with the highest risk of rebleeding. Hyphema complications include: 

    • Obstruction of trabecular meshwork with associated intraocular pressure elevation
    • Formation of peripheral anterior synechiae
    • Posterior synechiae
    • Corneal blood staining
    • Pupillary block
    • Amblyopia (in the pediatric population)
    • Rebleeding

    Rebleeding typically occurs within the first five days. It occurs when the initial clot lyses and the fragile damaged vessel wall breaks down, leading to a second episode of bleeding. The rebleed is typically more significant than the initial bleed, which carries a higher risk of associated complications. 

    The risk of rebleeding is usually higher in patients with elevated intraocular pressure, a large hyphema, hypertension, history of using aspirin or other blood thinners (such as warfarin,apixaban, or NSAIDs), and those who are African American. 

    Short and Long-Term Follow-Up

    Hyphemas that are uncomplicated can be managed conservatively with an eye shield, limiting their activity, and elevating the head of the patient’s bed to at least 45 degrees. Head elevation allows for the hyphema to settle inferiorly within the anterior chamber, which avoids visual obstruction and limits exposure of the cornea and trabecular meshwork to the red blood cells. 

    Use of topical steroids and cycloplegics is often initiated in the short term to encourage healing of the ocular structures and minimize movement of the damaged iris vessels. 

    Short-term repeat outpatient follow-up is appropriate for visual acuity, intraocular pressure, and hyphema status evaluations. However, for patients with bleeding disorders, other severe ocular injuries, and known sickle cell trait or disease, you may consider closer outpatient  monitoring or hospitalization. During the initial stages of healing, excessive physical activity should be avoided, an eye shield should be worn at all times, eye rubbing should be discouraged, and close observation by the patient and family for signs and symptoms of elevated intraocular pressure or rebleeding should be encouraged. 

    Patients with blunt ocular trauma leading to hyphema are at risk of other ocular complications as well, both in the short and long term. Early on, presence of additional traumatic complications such as retinal tears or detachments, vitreous hemorrhage, and commotio retinae should be ruled out. 

    In the long term, monitoring for complications such as traumatic cataract, traumatic mydriasis, angle recession, and glaucoma is important. While no formal recommendations exist for the frequency or longevity of follow-up, regular long-term eye visits should be instituted for most patients suffering from hyphema.

    Medication Therapy 

    Topical or systemic corticosteroids may reduce inflammation. Topical cycloplegic drops may aid in patients with ciliary spasm or photophobia, as well as stabilize traumatized iris vessels. Aqueous suppressants are the first line for managing intraocular pressure, namely beta blockers and alpha agonists. 

    If topical management does not control intraocular pressure, consider prescribing systemic carbonic anhydrase inhibitors and hyperosmotic agents (such as mannitol). Do not prescribe carbonic anhydrase inhibitors for patients with sickle cell disease or trait, however, as the increase in aqueous acidity increases the risk of red blood cell sickling. Systemic and topical aminocaproic acid has been used to avoid a secondary hemorrhage in hyphema patients, though they are not routinely used. 

    Surgery as an Appropriate Intervention 

    About 5% of patients with a traumatic hyphema require surgery. Most hyphemas resolve with medical management only. 

    Surgical management may be considered if the patient develops uncontrolled glaucoma, corneal blood staining, persistent large hyphema, and/or active bleeding into the anterior chamber. Uncontrolled intraocular pressure in the setting of hyphema is defined as greater or equal to 50 mmHg for more than five days, or more than 25 mmHg for more than 24 hours in a patient with sickle cell disease or trait despite maximal medical therapy. Keep in mind that pediatric patients can develop amblyopia if a large hyphema completely obstructs vision, and so you may consider surgical intervention for this population as well. 

    Surgery typically involves an anterior chamber washout, irrigation and aspiration, vitrectomy, or trabeculectomy with placement of a glaucoma drainage device. You can perform anterior chamber paracentesis as a temporizing measure for controlling elevated intraocular pressure. Peripheral iridectomy may be appropriate if there is a risk of a pupillary block from a total hyphema. 

    Patient Information

    What Is Hyphema? American Academy of Ophthalmology

    Hyphema and the Upright Position. American Academy of Ophthalmology

    How Long Before the Blood Clears From My Eye After Getting a Hyphema? American Academy of Ophthalmology

    Further Resources 

    Hyphema. EyeWiki 

    Hyphema. American Academy of Ophthalmology

    Corneal Blood Staining. EyeWiki

    Video: Traumatic Hyphema. American Academy of Ophthalmology

    Case Study: Spontaneous Hyphema. American Academy of Ophthalmology

    Video: Managing Hyphema From Prior Bleb Revision. American Academy of Ophthalmology

    Wills Eye Manual, 8th Edition, Section 3.6 (point No. 7 under treatment)

    The Academy’s YO Info editorial board is collaborating with YO leaders from our subspecialty and specialized interest society partners and thanks the American Society of Ophthalmic Trauma (ASOT) for contributing to this article. ASOT will hold its annual meeting, Eye Trauma 2024, May 17-18, in Houston.

    About the authors:

    Headshot of JGabriella Schmuter, MD Gabriella Schmuter, MD, is a PGY-2 ophthalmology resident at NewYork-Presbyterian Weill Cornell Medical Center in New York City. Her academic and research interests include oculofacial plastic and reconstructive surgery, medical education, and health care quality improvement.
    Headshot of Grayson W. Armstrong, MD, MPH Grayson W. Armstrong, MD, MPH, is the director of ophthalmology emergency services at Massachusetts Eye and Ear Infirmary. Dr. Armstrong also serves as an instructor of ophthalmology and associate director of medical student education at Harvard Medical School. He practices as a comprehensive ophthalmologist and medical retina specialist. He joined the YO Info editorial board in 2022.
    Headshot of Grant A. Justin, MD Grant A. Justin, MD, is a major in the United States Army and ASOT president. He is an adult and pediatric vitreoretinal surgeon at Walter Reed National Military Medical Center and an assistant professor at the Uniformed Services University.