Hyphema

Presentation

1. DEPT. OF OPTHALMOLOGY
SHER-E-BANGLA MEDICAL COLLEGE HOSPITAL, BARISAL.
HYPHEMA

DR. MD. NURUL ISLAM
DO STUDENT
SESSION – JULY, 2013
12-11-2013

2. Definition:
Blood in the anterior chamber of eye is called
Hyphema.

3. Pathophysiology:
•Compressive force to the globe or trauma can result
in injury to the iris, ciliary body, trabecular
meshwork, and their associated vasculature. The
shearing forces from the injury can tear these vessels
and result in the accumulation of blood cells within
the anterior chamber.
Fig; Bleeding from the ciliary body

4. Classification
Etiological:
1.Traumatic hyphaema
- most commonly blunt trauma
2.Strenuous conditions
- Whooping cough, Asthma etc.
3.Blood dyscrasia
- Aplastic anaemia, leukemia, hemophilia,
von Willebrand disease etc.
4.Neovascularization (Rubeosis iridis)
- Diabetes mellitus, CRVO, BRVO

5. Classification
Etiological:
5.Miscellaneous
- Herpetic keratouveitis
- Intraocular tumors (retinoblastoma, iris
melanoma etc.)
- Vascular anomaly - juvenile xanthogranuloma (JXG)
- Secondary to ocular surgery or laser
- Medications with anticoagulant properties
(aspirin, NSAIDs, warfarin or clopidogrel etc.)

6. Classification
Clinical:
1.Mild or simple hyphema (2-3mm)
2.Moderate hyphema (3-5mm)
3.Severe hyphema – more than half of A/C
4.Total hyphema – A/C full of blood

7. Grading
•Grade 0: No visible layering, but red
blood cells within the anterior
chamber (microhyphaema)
•Grade I: Layered blood occupying less
than 1/3 of the anterior chamber
•Grade II: Blood filling 1/3 to 1/2 of
the anterior chamber
•Grade III: Layered blood filling ½ to
less than total of the anterior
chamber
•Grade IV: Total clotted blood, often
referred to as blackball or 8-ball
hyphaema
Hyphaemas can be graded from I-IV in the following manner:

8. Presentation

9. Presentation
•Symptoms:
Symptoms can be variable depending on the
etiology. Typically patients complain of blurry
vision, pain, headahce, photophobia, H/O
trauma.
•Signs:
Blood or clot or both in the AC, usually visible
without a slit lamp.

10. Examinations/Work-up
1.History:
Detailed including -
- Mechanism of injury
- Time of injury with time of visual loss(if any)
- H/O medications (aspirin, warfarin etc.)
- H/O Sickle cell disease (familial or personal?)
- Any H/O coagulopathy- bleeding gums,
epistaxis etc.

11. Examinations/Work-up
2.Ocular examinations:
- Rule out any rupture globe or penetrating
injuries
- Visual acuity
- IOP
- Slit lamp examination
- B-scan (gently) if A/C filled with blood
- CT may be done if suspected orbital fracture or
IOFB

12. Management

13. Principles of management:
1. Quick absorption of blood (rest of the pt. rest
of the eye)
2. Prevention of complication (aggressive Rx for
children especially those at risk of amblyopia)
3. Avoidance of recurrence
4. Discontinuation any anticoagulation
medication
5. Limiting activities, rest with semi-upright
posture including during sleeping

14. Treatment: (Medical)
1. Sedation or complete bed rest with limited
activites.
2. Cycloplegics; Atropine 1% E/D
3. Anti inflamatoty
- Steroids, mild NSAIDs
4. Ocular hypotensive agents in case of IOP (if
bilateral systemic should be added)
5. Place shield or patch over involved eye or
both eyes (controversial)
6. Rx of the cause

15. Treatment: (Surgical)
- A/C paracentes with irrigation and aspiration
Indications:
- Corneal blood staining
- Significant visual deterioration
- to prevent optic atrophy
(IOP >60 mm Hg for >48 hours, despite maximal
medical therapy)
- to prevent peripheral anterior synechiae (PAS)
(Hyphema <50% for 8 days)
- IOP >25 mm Hg with total hyphema for >5 days
- IOP 24 mm Hg for >24 hours (or any transient
increase in IOP >30 mm Hg) in sickle cell disease/trait
patients

16. Complications:
•Obstruction of trabecular meshwork with associated
IOP elevation
•Peripheral anterior synechiae (PAS)
•Posterior synechiae
•Corneal blood staining
•Rebleeding
•Pupillary block
•Amblyopia (pediatric patients)

17. Follow-Up:
1. Hospitalized pt. should be monitored everyday for
V/A, IOP and slit-lamp examinations
2. After discharge next follow-up would be after 2-3
days
3. Then several days to 1 week according to severity
4. After 4 weeks Gonioscopy and detailed fundus
examination is must for all patients

18. Prognosis:
Success of hyphaema Rx is judged by the recovery
of visual acuity, it is good in approximately 75% of
patients and in those-
•Hyphema <1/3 of AC - - VA 6/12 or better in 80% cases
•Hyphema <1/2-2/3 of AC - - VA 6/12 or better in 60%
cases
•Hyphema <1/3 of AC - - VA 6/12 or better in 80% cases
•while only approximately 35% of cases with an initially
total or a Grade 4 hyphema have good visual results

19. References:
1. Lecture notes - Professor Dr. Md. Shahidul Alam FCPS
Head of the Dept. of Opthalmology,
Sher-E-Bangla Medical College Hospital, Barisal.
2. Jack J Kanski Brad Bowling
Clinical Ophthalmology A SYSTEMATIC APPROACH 7
th
Edition
3. The Wills Eye Manual
Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition
4. http://eyewiki.aao.org/
5. http://www.medscape.com/

20. THANK YOU