Traumatic hyphema: Clinical features and diagnosis
- Christopher M Andreoli, MD
Christopher M Andreoli, MD
- Clinical Instructor in Ophthalmology
- Harvard Medical School
- Matthew F Gardiner, MD
Matthew F Gardiner, MD
- Assistant Professor of Ophthalmology
- Harvard Medical School
- Section Editors
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Associate Professor of Pediatrics
- Harvard Medical School
- Jonathan Trobe, MD
Jonathan Trobe, MD
- Section Editor — Ophthalmology
- Professor of Ophthalmology and Visual Sciences
- Professor of Neurology
- University of Michigan Kellogg Eye Center
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
Traumatic hyphema, or blood in the anterior chamber, is a common complication of blunt or penetrating injury to the eye and can result in permanent vision loss. The goals of initial assessment include recognition and characterization of the hyphema and identification of associated orbital and ocular injuries. If ruptured globe is suspected, then emergent consultation with an ophthalmologist is critical to ensure preservation of vision. In addition, optimal outcome following a hyphema depends on early ophthalmologic intervention focused on prevention of rebleeding and avoidance of intraocular hypertension. In most instances, patients recover with vision intact. Vision loss is more likely in patients with large hyphemas, sickle hemoglobinopathy or trait, or bleeding tendency.
This review covers the clinical features and diagnosis of traumatic hyphema. The management of traumatic hyphemas is discussed separately. (See "Traumatic hyphema: Management".)
●Hyphema refers to grossly visible blood in the anterior chamber of the eye (picture 1).
●Microhyphema describes dispersed red blood cells in the anterior chamber that do not layer out to form a gross fluid level (figure 1).
Incidence — The annual incidence of traumatic hyphema has been estimated at 12 injuries per 100,000 population, with males being affected three to five times more frequently than females [1-4]. Up to 70 percent of traumatic hyphemas occur in children, with a peak incidence between 10 and 20 years of age [1,3,4].
- Kennedy RH, Brubaker RF. Traumatic hyphema in a defined population. Am J Ophthalmol 1988; 106:123.
- Agapitos PJ, Noel LP, Clarke WN. Traumatic hyphema in children. Ophthalmology 1987; 94:1238.
- Edwards WC, Layden WE. Traumatic hyphema. A report of 184 consecutive cases. Am J Ophthalmol 1973; 75:110.
- Walton W, Von Hagen S, Grigorian R, Zarbin M. Management of traumatic hyphema. Surv Ophthalmol 2002; 47:297.
- Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg 2001; 59:1462.
- Pashby T. Eye injuries in Canadian amateur hockey. Can J Ophthalmol 1985; 20:2.
- Sankar PS, Chen TC, Grosskreutz CL, Pasquale LR. Traumatic hyphema. Int Ophthalmol Clin 2002; 42:57.
- Napier SM, Baker RS, Sanford DG, Easterbrook M. Eye injuries in athletics and recreation. Surv Ophthalmol 1996; 41:229.
- Rahmani B, Jahadi HR, Rajaeefard A. An analysis of risk for secondary hemorrhage in traumatic hyphema. Ophthalmology 1999; 106:380.
- Spoor TC, Kwitko GM, O'Grady JM, Ramocki JM. Traumatic hyphema in an urban population. Am J Ophthalmol 1990; 109:23.
- Alfaro DV 3rd, Jablon EP, Rodriguez Fontal M, et al. Fishing-related ocular trauma. Am J Ophthalmol 2005; 139:488.
- Motley WW 3rd, Kaufman AH, West CE. Pediatric airbag-associated ocular trauma and endothelial cell loss. J AAPOS 2003; 7:380.
- Cavallini GM, Lugli N, Campi L, et al. Bottle-cork injury to the eye: a review of 13 cases. Eur J Ophthalmol 2003; 13:287.
- Brouzas D, Charakidas A, Papagiannakopoulos D, Koukoulomatis P. Elastic cord-induced ocular injuries. Injury 2003; 34:323.
- Kratz A, Levy J, Cheles D, et al. Airsoft gun-related ocular injuries: novel findings, ballistics investigation, and histopathologic study. Am J Ophthalmol 2010; 149:37.
- Thach AB, Ward TP, Hollifield RD, et al. Ocular injuries from paintball pellets. Ophthalmology 1999; 106:533.
- Farr, AK, Fekrat, S. Eye injuries associated with paintball guns. Int Ophthalmol 1998-1999; 22:169.
- Alliman KJ, Smiddy WE, Banta J, et al. Ocular trauma and visual outcome secondary to paintball projectiles. Am J Ophthalmol 2009; 147:239.
- Read JE, Goldberg MF. Blunt ocular trauma and hyphema. Int Ophthalmol Clin 1974; 14:57.
- HORVEN I. ERYTHROCYTE RESORPTION FROM THE ANTERIOR CHAMBER OF THE HUMAN EYE. Acta Ophthalmol (Copenh) 1963; 41:402.
- Lifshitz T, Yermiahu T, Biedner B, Yassur Y. Traumatic total hyphema in a patient with severe hemophilia. J Pediatr Ophthalmol Strabismus 1986; 23:80.
- McDonald CJ, Raafat A, Mills MJ, Rumble JA. Medical and surgical management of spontaneous hyphaema secondary to immune thrombocytopenia. Br J Ophthalmol 1989; 73:922.
- Kageler WV, Moake JL, Garcia CA. Spontaneous hyphema associated with ingestion of aspirin and ethanol. Am J Ophthalmol 1976; 82:631.
- Arentsen JJ, Green WR. Melanoma of the iris: report of 72 cases treated surgically. Ophthalmic Surg 1975; 6:23.
- Blanksma LJ, Hooijmans JM. Vascular tufts of the pupillary border causing a spontaneous hyphaema. Ophthalmologica 1979; 178:297.
- Bruner WE, Stark WJ, Green WR. Presumed juvenile xanthogranuloma of the iris and ciliary body in an adult. Arch Ophthalmol 1982; 100:457.
- Shields CL, Ghassemi F, Tuncer S, et al. Clinical spectrum of diffuse infiltrating retinoblastoma in 34 consecutive eyes. Ophthalmology 2008; 115:2253.
- Koehler MP, Sholiton DB. Spontaneous hyphema resulting from warfarin. Ann Ophthalmol 1983; 15:858.
- Calzada JI, Kerr NC. Traumatic hyphemas in children secondary to corporal punishment with a belt. Am J Ophthalmol 2003; 135:719.
- Cohen SB, Fletcher ME, Goldberg MF, Jednock NJ. Diagnosis and management of ocular complications of sickle hemoglobinopathies: Part V. Ophthalmic Surg 1986; 17:369.
- Nasrullah A, Kerr NC. Sickle cell trait as a risk factor for secondary hemorrhage in children with traumatic hyphema. Am J Ophthalmol 1997; 123:783.
- Trauma. In: The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th edition, Ehlers JP, Shah CP. (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.12.
- Harlan JB Jr, Pieramici DJ. Evaluation of patients with ocular trauma. Ophthalmol Clin North Am 2002; 15:153.
- Arey ML, Mootha VV, Whittemore AR, et al. Computed tomography in the diagnosis of occult open-globe injuries. Ophthalmology 2007; 114:1448.
- Restori M. Imaging the vitreous: optical coherence tomography and ultrasound imaging. Eye (Lond) 2008; 22:1251.
- Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med 2002; 9:791.
- Pavlin CJ, Foster FS. Ultrasound biomicroscopy. High-frequency ultrasound imaging of the eye at microscopic resolution. Radiol Clin North Am 1998; 36:1047.
- Carrasquillo AM, Gupta BK, Wilensky JT. Recurrent hyphema in an aphakic child: Swan syndrome. J AAPOS 2001; 5:55.
- Alomari AI. Persistent fetal vasculature and spontaneous hyphema in a patient with Klippel-Trenaunay-Weber syndrome. J AAPOS 2010; 14:376; author reply 376.
- Shields JA, Eagle RC Jr, Ewing MQ, et al. Retinal cavernous hemangioma: fifty-two years of clinical follow-up with clinicopathologic correlation. Retina 2014; 34:1253.
- Elgin U, Sen E, Teke MY, et al. Microtrauma-induced recurrent hyphema and secondary glaucoma associated with chronic acetylsalicylic acid use. Int Ophthalmol 2012; 32:89.
- Hack KM, Pedersen R. Mental status changes and bradycardia: don't forget the eye! Traumatic hyphema can mimic increased intracranial pressure. Clin Pediatr (Phila) 2009; 48:331.
- Cohn JN, Scagliotti D, Deutsch TA. Bradycardia with traumatic hyphema in children. J Pediatr Ophthalmol Strabismus 1987; 24:315.
- Mechanism of injury
- Traumatic hyphema
- Spontaneous hyphema
- Predisposing conditions
- CLINICAL FEATURES
- Physical examination
- - Precautions and approach
- - Findings of hyphema
- - Injury to adjacent structures
- Open globe
- Corneal abrasion
- Angle recession
- Laboratory testing
- Diagnostic imaging