Traumatic hyphema: Rapid overview of emergency management

History

Typically caused by blunt trauma to the orbit

Associated injuries: head trauma, orbital fracture, posterior segment injury (vitreous, retina, choroid, and/or optic nerve), and open globe (rare)

Risk factors for poor outcome: sickle cell disease or trait, bleeding tendency (eg, hemophilia, von Willebrand disease, or anticoagulated)

Causes of spontaneous hyphema (rare): diabetes mellitus, clotting disorder, eye tumor, or (in children) child abuse

Clinical features

Signs of open globe: Emergency ophthalmology consultation indicated if present!*

Markedly decreased visual acuity or relative afferent pupillary defect by swinging penlight technique

Eccentric or peaked pupil, uveal (iris or ciliary body) prolapse

Markedly increased or decreased anterior chamber depth

Extrusion of ocular contents or intraocular or protruding foreign body

Tenting of the sclera at site of globe puncture

Large circumferential subconjunctival hemorrhage

Clinical findings of hyphema: All patients with hyphema warrant prompt evaluation by an ophthalmologist.

Decreased visual acuity

Eye pain with pupillary constriction to bright light (direct and consensual)

Blood in the anterior chamber either grossly visible (hyphema) or visible with slit lamp exam (microhyphema)

Damage to adjacent structures or abnormal IOP Caution! Only measure IOP once an open globe is excluded and if skilled in the procedure.

Diagnostic evaluation

Comprehensive eye examination by an ophthalmologist

Solubility testing (eg, Sickledex) or hemoglobin electrophoresis in susceptible patients (eg, African or Mediterranean descent or positive family history) with uncertain sickle hemoglobin status

CBC, PT, PTT, INR for patients with bleeding dyscrasia; perform other blood and urine studies based on presence and degree of other injuries

Orbital CT without contrast with 1- to 2-mm axial and coronal cuts through the orbits if any one of the following:

Concern for an open globe

Concern for intraocular foreign body

Trauma patients undergoing cranial CT for other indications

Concern for orbital fracture (palpable step-off of inferior orbital ridge, limited extraocular movement, or significant periocular swelling)

Initial treatment

Assess and treat life-threatening injuries

If rapid sequence intubation necessary:

Rocuronium is preferred to succinylcholine for muscle relaxation

Succinylcholine may be used with dexmedetomidine premedication

For sedation, avoid ketamine

If bleeding tendency: Treat any underlying bleeding dyscrasia. For anticoagulated patients, consult with a specialist.

Place an eye shield without placing pressure on the affected eye and maintain except during eye examination.

Elevate the patient's head to 30 degrees and maintain the patient at bed rest.

Cycloplegia: Dilate pupil for examination; also provides pain relief. Caution! Do not dilate if an open globe is suspected; consult an ophthalmologist.

Instill 1 drop of cyclopentolate 1% ophthalmic solution (full dilation in approximately 25 minutes)

Control nausea and vomiting: Administer ondansetron (in adults, 4 mg; in children, 0.15 mg/kg, maximum single dose: 4 mg) IV or orally.^¶

Pain: Topical pain control. Caution! Do not instill if an open globe is suspected; consult an ophthalmologist.

Instill 1 drop of 0.5% proparacaine ophthalmic solution or

Instill 1 drop of 0.5% tetracaine ophthalmic solution

May repeat topical anesthetic after 5 to 10 minutes if needed

Additional pain control: If topical pain control is insufficient, give

Oral oxycodone 0.15 mg/kg (maximum 5 mg) or

IV/SQ morphine 0.1 mg/kg (maximum 8 mg) or

IV fentanyl 1 to 2 mcg/kg (maximum 25 to 50 mcg), may repeat after 3 to 5 minutes if needed

Acetaminophen (paracetamol) 15 mg/kg orally (maximum 1 g) is also useful; do not give NSAIDs

Ensure definitive management by an ophthalmologist

IOP: intraocular pressure; CBC: complete blood count; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; CT: computed tomography; IV: intravenous; SQ: subcutaneous; NSAIDs: nonsteroidal antiinflammatory drugs (eg, ibuprofen, ketorolac); ECG: electrocardiogram.

* Refer to UpToDate topics on open globe injuries.

¶ Ondansetron should be avoided in patients with congenital long QT syndrome. ECG monitoring should be performed for patients receiving ondansetron who also have the following conditions: electrolyte abnormalities (eg, hypokalemia, hypomagnesemia), congestive heart failure, or bradyarrhythmias; or are taking medications that prolong the QT interval.

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Traumatic hyphema: Rapid overview of emergency management