Introduction
A hyphema refers to a collection of blood in the anterior chamber of the eye. That is, between the cornea and the iris. The cornea is the transparent covering of the eye while the pupil is the colored part. Both are located at the front of the eye. The blood may collect around parts or all of the iris and the pupil (round dark circle in the middle of the eye). Hyphema partly or totally blocks vision in the affected eye. Increased pressure within the eye (glaucoma) and blood staining the cornea may lead to vision loss.
A hyphema may sometimes be confused with subconjunctival hemorrhage. The latter is a broken vessel in the front of the eye. A subconjunctival hemorrhage is painless, ordinary and harmless while a hyphema is painful and can lead to permanent vision problems. It is a medical emergency that requires immediate attention.
Sub-Types
- Traumatic hyphema - Caused by blunt or penetrating trauma to the eye
- Spontaneous hyphema - Caused by medical conditions such as leukemia
Other subtypes include:
- Microhyphema (blood is not visible)
- Total hyphema (red blood fills the anterior chamber of the eye)
- Blackball or 8-ball hyphema (dark-red blood fills the anterior chamber)
Causes and Risk Factors
An injury or blunt trauma is responsible for hyphema. Additional bleeding may continue for 3-5 days in the absence of trauma. The following can also cause hyphema:
- Surgery
- Abnormal blood vessels in the eye
- Severe iris inflammation
- Blood disorders like sickle cell anemia
- Advanced diabetes and other medical conditions
- Eye infections caused by a herpes virus
- Artificial lens after cataract surgery
- Cancer of the eye (rarely)
Those at risk include sportspeople. Others include workers who use power tools without eye protection.
Children are also predisposed due to play. Individuals involved in accidents and fights risk developing hyphema.
Signs & Symptoms
The signs of hyphema are graded from 0-1V:
Grade 0: Microhyphema (blood is not visible)
Grade I: A layer of blood sitting on less than a third of the anterior chamber
Grade II: Blood filling one third to a half of the anterior chamber
Grade III: A layer of blood filling one half to less than a total of the anterior chamber
Grave IV: Blood entirely filling the anterior chamber. Also known as total hyphema
Symptoms of hyphema may include:
- Pain in the eye
- Bleeding in the front part of the eye
- Blurred or blocked vision
- Sensitivity to light
- Visible hyphema if it’s large enough
Diagnosis
The eye professional will do a complete eye examination. He/she will need to take the history of the injury to determine when and how the trauma occurred. African Americans with hyphema must be checked for sickle cell anemia. The professional will also do the following:
- Perform visual acuity tests to determine how well the patient can see. He/she will check the inside of the eye and the intraocular pressure
- Do a dilated examination to examine the fundus of the eye. This examination is essential to ensure there is no additional injury such as retinal detachment
- Use a slit lamp (special microscope) to check the internal structures of the eye
- A CT scan is necessary to check the condition of the eye sockets and facial structure
Treatment
Treatment of hyphema is aimed at encouraging the blood to clear from the eye. It is also focused on treating any elevated intraocular pressure and preventing additional bleeding.
Medical Treatment
In mild cases, treatment is not necessary. The blood will clear on its own within a few days. If a medical condition caused the bleeding, separate treatment is required.
Steroid eye drops may be prescribed to help reduce inflammation and scarring. Also, dilating eye drops can help alleviate pain. Intraocular pressure is a concern. The eye doctor may take eye pressure daily using a tonometer. If the pressure is high, the patient may develop nausea, pain in the eye and
decreased vision. To reduce the pressure, the doctor will prescribe drops.
Should bleeding persist, the doctor may administer aminocaproic acid or tranexamic acid to the patient. These drugs hasten the clotting of blood.
Hyphema patients should not take any drug containing aspirin or ibuprofen. These drugs can make the bleeding worse.
Surgical Treatment
If the pressure inside the eye increases significantly or if the blood is not clearing, surgery should be performed. The operation will remove the blood and help relieve internal pressure. It will also help to open up clogged drainage channels.
In some cases, diabetic patients may require laser surgery.
Home Care
Bed rest or limited activity for several days will help in recovery. The head should be kept in an elevated position, even during sleep. The eye needs to have a protective shield over it. Reading is not be permitted during this period.
Once discharged from the hospital, hyphema patients should wear a protective shield for 2 weeks. They should also avoid strenuous activity for 2-4 weeks.
Prognosis/Long-term outlook
Excessive intraocular pressure can lead to glaucoma or eye damage.
Glaucoma is a result of blunt trauma which can irreversibly damage the drainage canals of the eye. The doctor uses a gonioscopy to determine if there is any damage. He/she will then recommend the appropriate treatment and follow-up.
Patients with sickle cell anemia are predisposed to eye complications. They require close monitoring.
Other complications may include severe or impaired vision loss and recurrent bleeding. There may also be damage to different structures of the eye.
Daily visits or a stay at the hospital are recommended. In some cases, patients will require follow-up visits every day for five days. Then weekly or monthly visits will follow until healing is achieved. Children and the elderly require a hospital stay for closer monitoring.
Any person who has been treated for hyphema previously should go for annual check ups to prevent the development of glaucoma.
Prevention/Follow Up
Patients should wear protective gear while doing sports activities like racquetball. Those whose work involves power instruments should also wear safety goggles.
