Hyphema: Definition, Causes, and Treatment
Introduction
Hyphema is a medical condition characterized by the presence of blood within the anterior chamber of the eye, the space between the cornea and the iris. This accumulation of blood can partially or completely obscure vision and is considered an ocular emergency due to the risk of vision loss and other complications.
What is Hyphema?
• Definition: Hyphema refers to the pooling or collection of blood in the anterior chamber of the eye.
Classification:
Microhyphema: Only red blood cells are visible in the anterior chamber, but no visible layering of blood.
Grade 1: Less than one-third of the anterior chamber is filled with blood.
Grade 2: One-third to one-half of the chamber is filled.
Grade 3: More than half but less than the total chamber is filled.
Grade 4: Total filling of the anterior chamber, sometimes called "eight-ball hyphema" when the blood appears black.
Causes of Hyphema
1. Trauma
Blunt Trauma: The most common cause, often resulting from sports injuries, falls, or accidents.
Penetrating Trauma: Less common but more severe, caused by sharp objects entering the eye.
2. Non-Traumatic Causes
Ocular Surgery: Postoperative complications can lead to hyphema.
Neovascularization: Abnormal blood vessel growth, often due to diabetes or retinal vein occlusion.
Blood Disorders: Conditions such as hemophilia, sickle cell disease, or use of anticoagulant medications can increase bleeding risk.
Tumors: Intraocular tumors may cause spontaneous bleeding.
Clinical Presentation
Symptoms:
• Visible blood in the anterior chamber
• Sensitivity to light (photophobia)
• Eye pain or discomfort
• Decreased vision or blurry vision
Signs:
• Increased intraocular pressure (IOP) in some cases
• Layering of blood visible on slit-lamp examination
Complications
Increased Intraocular Pressure: Blood can block the normal drainage of aqueous humor, leading to glaucoma.
Corneal Blood Staining: Prolonged contact of blood with the cornea can cause permanent staining and vision loss.
Rebleeding: Risk is highest within the first week after the initial injury.
Optic Nerve Damage: Due to sustained high intraocular pressure.
Treatment of Hyphema
1. Initial Management
Bed Rest: Elevate the head to 30-45 degrees to promote settling of blood and reduce risk of rebleeding.
Eye Shield: Protect the eye from further injury.
Avoidance of NSAIDs and Aspirin: These medications can increase bleeding risk.
2. Medical Therapy
Topical Steroids: Reduce inflammation and prevent further bleeding.
Cycloplegic Agents: Dilate the pupil and relieve pain.
Antiglaucoma Medications: Lower intraocular pressure if elevated.
Pain Management: Acetaminophen is preferred.
3. Monitoring
Frequent Eye Examinations: Monitor for rebleeding, increased IOP, and corneal staining.
Blood Pressure and Coagulation Status: Especially in patients with underlying systemic conditions.
4. Surgical Intervention
Indications: Persistent high intraocular pressure, total hyphema not resolving, corneal blood staining, or non-resolving hyphema after several days.
Procedures: Anterior chamber washout or paracentesis to remove blood.
Prevention and Patient Education
Protective Eyewear: Especially during sports or high-risk activities.
Control of Systemic Diseases: Proper management of diabetes, hypertension, and blood disorders.
Medication Review: Avoid unnecessary use of anticoagulants or NSAIDs in at-risk individuals.
Conclusion
Hyphema is a potentially sight-threatening condition that requires prompt recognition and management. Trauma remains the leading cause, but non-traumatic etiologies should also be considered. Treatment focuses on preventing complications, managing intraocular pressure, and promoting resolution of the hemorrhage. Early intervention and patient education are key to preserving vision and preventing recurrence.