• A hyphema is a collection of blood in the ocular anterior chamber.
• Most commonly occur as sequelae of blunt or penetrating eye trauma.
• Can occur spontaneously in populations that are prone to bleeding (i.e. hemophilia).
• In the context of penetrating trauma, hyphemas may be associated with globe rupture or intraocular foreign body.
• Hyphemas require prompt referral to ophthalmology to minimize the potential for vision loss.
• The majority of patients recover with intact vision, but severity is correlated with degree of vision loss.

History

• Symptoms include vision loss or blurring, eye pain, nausea, and vomiting.
• Common mechanisms include sporting injuries, assault, projectile trauma, or airbag deployment.
• Spontaneous hyphemas: diabetes mellitus, ocular tumours, clotting disorders, or those on anticoagulation therapy (i.e. warfarin, DOAC).
• Risk factors for poor outcome (i.e. sickle cell, bleeding disorders).

Physical

• Exclude open globe and orbital compartment syndrome.
  • Emergent ophthalmology consult.
• Penlight yields a layer of RBCs in the anterior chamber (patient in a seated position).
• Assessment should also include:
  • Evaluation of the peri-orbital structures
  • Evaluation of a RAPD
  • Visual acuity, visual fields
  • Extra-ocular muscle function
• Common physical exam findings include:
  • Photophobia
  • Decreased visual acuity (worse in supine)
  • Anisocoria
  • Elevated intraocular pressure (>21 mmHg)
  • Corneal blood staining
• Examination may be aided with reducing ambient light and topical analgesic, if necessary.
• Slit lamp examination may be used to grade severity or detect microhyphema.
• Evaluation for other associated conditions (see below).

Associated Conditions

• Globe rupture
• Corneal abrasion
• Traumatic iritis
• Lens subluxation or phacodonesis
• Angle recession
• Synechiae

Imaging

• Emergent imaging should be obtained in all patients with concern for serious orbital injury, or have presence of hemorrhage that obscures viewing of the posterior structures of the eye with physical examination.

CT Scan

• Orbital CTs should be obtained if suspicion of open globe, intraocular foreign bodies and intraorbital hemorrhage, or orbital fracture in trauma patients.

Ocular ultrasonography

• Assess for lens damage, intraocular foreign bodies, retinal detachment or choroidal hemorrhage in patients where radiation exposure is acutely detrimental.
• Should not be used if globe rupture suspected.

Other Investigations

• If unknown status and susceptible population, confirm Sickle Cell status with solubility testing or hemoglobin electrophoresis.
• Evaluate for bleeding risk – PT/PTT.
• If spontaneous hyphema, evaluate for potential underlying causes:
  • Diabetes mellitus or other vascular abnormalities
  • Bleeding disorders or anticoagulation
  • Ocular tumours
  • Child abuse
  • Juvenile xanthogranuloma

• Consult ophthalmology

Initial Management

Management of other life-threatening trauma.

• If rapid sequence intubation required in the setting of increased intraocular pressure:
  • Rocuronium preferred to succinylcholine.
  • Succinylcholine may be used if pre-medicating with dexmedetomidine.
• Protection of the injured eye
  • Eye shielding with metal or plastic shield only
  • Bed rest and activity limitation
  • Dim lighting and placement in a quiet room
  • HOB elevated to > 30 degrees
  • Antiemetics (i.e. ondansetron)
• Analgesia
  • Topical (if no open globe suspected) – proparacaine, tetracaine
  • Oral – hydrocodone or oxycodone in combination with acetaminophen
  • IV (if large hyphema or multi-trauma) – morphine, fentanyl
• Dilating eye drops (if narrow angle glaucoma and open globe excluded) for analgesia & to aid examination
  • Cycloplegics – cyclopentolate 1% (1 drop, QID); or atropine 1% (1 drop, BID); or scopolamine 0.25% (1 drop, BID)
• Minimize risk of re-bleeding
  • Correction of bleeding disorders
  • Consideration of discontinuation or reversal of anticoagulation if benefits outweigh risks
• Treatment to be discussed with or directed by ophthalmology
  • Lowering of intraorbital pressure to <21 mmHg
  • Topical steroid use

Medications to Avoid

• NSAIDs (antiplatelet properties)
• Pilocarpine (pupil constriction)
• Prostaglandin eyedrops (pro-inflammatory)
• In sickle cell patients: carbonic anhydrase inhibitor and mannitol

• Other associated ocular/orbital injuries require close observation (i.e. ruptured globe)
• Children < 7 years old
• Elevated intraocular pressure
• Presence of risk factors for poor outcome (i.e. sickle hemoglobinopathy, bleeding disorder)
• Inability to adhere to treatment (i.e. activity restriction, medication compliance, social marginalization, tenuous housing, barriers to seeing ophthalmologist, etc.)

• Emergent ophthalmologic consultation indicated if:
  • Suspected orbital compartment syndrome or open globe
  • Grade III-IV hyphema
  • Presence of poor prognostic factors – high bleeding risk or sickle hemoglobinopathy
  • Elevated intraocular pressure
  • Visual acuity <20/200
• Otherwise, all patients with traumatic hyphema should receive urgent ophthalmology consults within 24 hours.

• Ensure arrangement of timely and appropriate ophthalmology consult (as above).
• Patients must be able to adhere to minimization of physical activity and medication regimens.
• Patients should be educated on symptoms of re-bleeding, elevated intraocular pressure, or retinal detachment.
• Antiemetics and stool softeners may be considered to decrease risk of increased intraocular pressure and re-bleeding.

1. Andreoli CM, Gardiner MF. Traumatic hyphema: Management. UpToDate. Updated Jul 13, 2020. Accessed May 15, 2021.

   
   

2. Brandt MT, Haug RH. Traumatic hyphema: A comprehensive review. J Oral Maxoillofac Surg. 2001;59(12):1672-70.

   
   

3. Gragg J, Blair K, Baker MB. Hyphema. StatPearls. Updated Dec 19, 2020. Accessed May 14, 2021.

   
   

4. Moussa K. Hyphema – Emergency Management. Dynamed. Updated Nov 30, 2018. Accessed May 15, 2021.