Traumatic hyphema: Clinical features and management
- 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
- Professor of Pediatrics and Emergency Medicine
- 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
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of 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. Although discussed separately, the assessment and management are performed jointly in practice (table 1).
If ruptured globe is suspected, then emergent consultation with an ophthalmologist is critical to help preserve 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 hemoglobinopathies, or bleeding dyscrasias.
This review covers the clinical features, initial and definitive management of traumatic hyphema. Epidemiology, anatomy, and pathophysiology are covered elsewhere. (See "Traumatic hyphema: Clinical features and diagnosis".)
A rapid overview summarizes the important clinical features and initial management of traumatic hyphema (table 1).
History — Vision loss and eye pain are common presenting complaints in patients with a traumatic hyphema. In addition, nausea and vomiting may accompany this injury .
- Sankar PS, Chen TC, Grosskreutz CL, Pasquale LR. Traumatic hyphema. Int Ophthalmol Clin 2002; 42:57.
- Spoor TC, Kwitko GM, O'Grady JM, Ramocki JM. Traumatic hyphema in an urban population. Am J Ophthalmol 1990; 109:23.
- Pashby T. Eye injuries in Canadian amateur hockey. Can J Ophthalmol 1985; 20:2.
- Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg 2001; 59:1462.
- Walton W, Von Hagen S, Grigorian R, Zarbin M. Management of traumatic hyphema. Surv Ophthalmol 2002; 47:297.
- Napier SM, Baker RS, Sanford DG, Easterbrook M. Eye injuries in athletics and recreation. Surv Ophthalmol 1996; 41:229.
- 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.
- 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.
- Edwards WC, Layden WE. Traumatic hyphema. A report of 184 consecutive cases. Am J Ophthalmol 1973; 75:110.
- Read JE, Goldberg MF. Blunt ocular trauma and hyphema. Int Ophthalmol Clin 1974; 14:57.
- Mowafi HA, Aldossary N, Ismail SA, Alqahtani J. Effect of dexmedetomidine premedication on the intraocular pressure changes after succinylcholine and intubation. Br J Anaesth 2008; 100:485.
- 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.
- 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.
- Pollock T, Laliberté I, Wu J, Lyons C. Traumatic hyphema and immune thrombocytopenic purpura: late rebleeds associated with low platelet count. Can J Ophthalmol 2008; 43:717.
- Wilker SC, Singh A, Ellis FJ. Recurrent bleeding following traumatic hyphema due to mild hemophilia B (Christmas disease). J AAPOS 2007; 11:622.
- Crouch ER Jr, Crouch ER. Management of traumatic hyphema: therapeutic options. J Pediatr Ophthalmol Strabismus 1999; 36:238.
- Shiuey Y, Lucarelli MJ. Traumatic hyphema: outcomes of outpatient management. Ophthalmology 1998; 105:851.
- Witteman GJ, Brubaker SJ, Johnson M, Marks RG. The incidence of rebleeding in traumatic hyphema. Ann Ophthalmol 1985; 17:525.
- Wright KW, Sunalp M, Urrea P. Bed rest versus activity ad lib in the treatment of small hyphemas. Ann Ophthalmol 1988; 20:143.
- Fong LP. Secondary hemorrhage in traumatic hyphema. Predictive factors for selective prophylaxis. Ophthalmology 1994; 101:1583.
- Ng CS, Strong NP, Sparrow JM, Rosenthal AR. Factors related to the incidence of secondary haemorrhage in 462 patients with traumatic hyphema. Eye (Lond) 1992; 6 ( Pt 3):308.
- Agapitos PJ, Noel LP, Clarke WN. Traumatic hyphema in children. Ophthalmology 1987; 94:1238.
- Romano PE, Robinson JA. Traumatic hyphema: a comprehensive review of the past half century yields 8076 cases for which specific medical treatment reduces rebleeding 62%, from 13% to 5% (P<.0001). Binocul Vis Strabismus Q 2000; 15:175.
- Yasuna E. Management of traumatic hyphema. Arch Ophthalmol 1974; 91:190.
- Rynne MV, Romano PE. Systemic corticosteroids in the treatment of traumatic hyphema. J Pediatr Ophthalmol Strabismus 1980; 17:141.
- Pollard ZF. No rebleeds in 250 cases of traumatic hyphema with the Yasuna "No Touch" protocol. Binocul Vis Strabismus Q 2000; 15:250.
- Spoor TC, Hammer M, Belloso H. Traumatic hyphema. Failure of steroids to alter its course: a double-blind prospective study. Arch Ophthalmol 1980; 98:116.
- Rahmani B, Jahadi HR. Comparison of tranexamic acid and prednisolone in the treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1999; 106:375.
- Farber MD, Fiscella R, Goldberg MF. Aminocaproic acid versus prednisone for the treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1991; 98:279.
- Karkhaneh R, Naeeni M, Chams H, et al. Topical aminocaproic acid to prevent rebleeding in cases of traumatic hyphema. Eur J Ophthalmol 2003; 13:57.
- Pieramici DJ, Goldberg MF, Melia M, et al. A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. Ophthalmology 2003; 110:2106.
- Crouch ER Jr, Williams PB, Gray MK, et al. Topical aminocaproic acid in the treatment of traumatic hyphema. Arch Ophthalmol 1997; 115:1106.
- Gharaibeh A, Savage HI, Scherer RW, et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev 2013; 12:CD005431.
- Crouch ER Jr, Frenkel M. Aminocaproic acid in the treatment of traumatic hyphema. Am J Ophthalmol 1976; 81:355.
- Kraft SP, Christianson MD, Crawford JS, et al. Traumatic hyphema in children. Treatment with epsilon-aminocaproic acid. Ophthalmology 1987; 94:1232.
- Berríos RR, Dreyer EB. Traumatic hyphema. Int Ophthalmol Clin 1995; 35:93.
- Benner JD. Transcorneal oxygen therapy for glaucoma associated with sickle cell hyphema. Am J Ophthalmol 2000; 130:514.
- Read J. Traumatic hyphema: surgical vs medical management. Ann Ophthalmol 1975; 7:659.
- Kennedy RH, Brubaker RF. Traumatic hyphema in a defined population. Am J Ophthalmol 1988; 106:123.
- Campbell DG. Ghost cell glaucoma following trauma. Ophthalmology 1981; 88:1151.
- Bakri SJ, Peters GB 3rd. Sympathetic ophthalmia after a hyphema due to nonpenetrating trauma. Ocul Immunol Inflamm 2005; 13:85.
- CLINICAL FEATURES
- Physical examination
- - Hyphema
- - Globe rupture
- Injury to adjacent structures
- - Lens trauma
- - Angle recession
- - Synechiae
- PRIMARY EVALUATION AND MANAGEMENT
- Initial emergency assessment
- Ophthalmology consultation
- Laboratory testing
- Diagnostic imaging
- Emergency treatment
- DEFINITIVE MANAGEMENT
- Inpatient versus outpatient treatment
- Medical management
- - Limitation of activity
- - Eye shield
- - Cycloplegia
- - Topical glucocorticoids
- - Systemic glucocorticoids
- - Antifibrinolytics
- - Treatment of intraocular hypertension
- - Transcorneal oxygen
- Surgical management
- SUMMARY AND RECOMMENDATIONS