Traumatic hyphema: Management

INTRODUCTION — 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. Once life-threatening injuries are addressed, the goals of initial assessment include recognition and characterization of the hyphema as well as identification of associated orbital and ocular injuries. Although discussed separately, the assessment and management are, in practice, done together (table 1).

If an orbital compartment syndrome or open globe is suspected, then emergent consultation with an ophthalmologist is critical to help preserve vision. In addition, optimal outcome following a hyphema depends upon 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 initial and definitive management of traumatic hyphemas. Clinical features and diagnosis of traumatic hyphemas are discussed separately. (See "Traumatic hyphema: Clinical features and diagnosis".)

APPROACH — A rapid overview summarizes the important clinical features and initial management of traumatic hyphema (table 1).

The clinician should first address life-threatening and immediate vision-threatening conditions before proceeding with specific treatment of a traumatic hyphema as follows:

●Life-threatening trauma – Hyphema can occur as a result of blunt injury to the eye in the setting of a fall, blow to the head, or multiple trauma; or as a component of a penetrating injury. The standard trauma evaluation should be followed to evaluate for life-threatening injuries in multitrauma patients before attention is focused on the eye. (See "Initial management of trauma in adults" and "Trauma management: Approach to the unstable child" and "Management of acute moderate and severe traumatic brain injury".)

In patients requiring intubation, the potential for open globe or increased intraocular pressure presents relative contraindications for the use of succinylcholine. However, premedication with dexmedetomidine can mitigate increased intraocular pressure if true rapid sequence induction is necessary [1]. (See "Rapid sequence intubation in adults for emergency medicine and critical care", section on 'Paralysis with induction' and "Rapid sequence intubation (RSI) in children for emergency medicine: Medications for sedation and paralysis", section on 'Paralytic agents'.)

●Immediate threats to vision – The clinician should assess for an orbital compartment syndrome (picture 1) or an open globe (picture 2) and seek emergent ophthalmologic consultation if either is present. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Clinical features' and "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.)

Patients with signs of an orbital compartment syndrome (eg, proptosis, decreased visual acuity, diffuse subconjunctival hemorrhage, tight eyelids) require emergent lateral canthotomy and inferior cantholysis to decompress the orbit. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Orbital compartment syndrome' and "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome'.)

A rapid overview provides key clinical findings and management of patients with an open globe (table 2).

INDICATIONS FOR OPHTHALMOLOGY CONSULTATION OR REFERRAL — Whenever possible, all patients with a traumatic hyphema warrant prompt evaluation by an ophthalmologist to provide a comprehensive eye examination, including intraocular pressure measurement. In addition, patients with the following findings warrant emergent consultation with an ophthalmologist with expertise in managing eye injuries:

●Orbital compartment syndrome (see "Overview of eye injuries in the emergency department", section on 'Orbital compartment syndrome')

●Open globe (see "Open globe injuries: Emergency evaluation and initial management")

●Traumatic hyphema with any of the following features:

•Large (grade III or IV) hyphemas (figure 1 and picture 3)

•Hyphemas in patients with a bleeding tendency or sickle hemoglobinopathy (either disease or trait) as determined by history or screening during initial evaluation (see "Traumatic hyphema: Clinical features and diagnosis", section on 'Predisposing conditions')

•Hyphemas associated with elevated intraocular pressure

If prompt consultation with an ophthalmologist is not feasible but serious associated eye injury and elevated intraocular pressure can be reliably excluded, discussion with an ophthalmologist prior to emergency department discharge is suggested. These patients warrant timely referral for complete ophthalmologic examination within 24 hours.

INITIAL MANAGEMENT — The following general measures are recommended in patients with hyphema and comprise appropriate initial care (table 1) [2-4]:

●Eye shield – An eye shield should be placed over the affected eye as soon as possible and subsequently removed only as required for examination and imaging.

●Bed rest and dim lighting – Limitation of activity to bed rest with bathroom privileges should occur until initial evaluation is complete. The patient should be placed in a dim, quiet room and should not read so that visual accommodation does not further stress injured blood vessels.

●Elevate the head of the bed – Elevation of the head to 30 degrees promotes inferior settling of blood in the anterior chamber away from the visual axis while maintaining arterial blood flow to the eye relative to the fully erect position [2,3]. Thirty degree elevation of the head also improves diagnosis of secondary hemorrhage and aids in clearance of the hyphema.

●Control pain – Pain control improves patient comfort and facilitates eye examination [3]. Topical analgesia with proparacaine or tetracaine may be applied temporarily in patients without an open globe; long term use may cause corneal toxicity. Dilating eye drops, discussed below, may also provide some pain relief. Nonsteroidal antiinflammatory agents (NSAIDS) are discouraged because of their platelet inhibiting properties.

For patients in whom topical analgesia is inadequate, the clinician may consider oral or intravenous opioids. Hydrocodone or oxycodone in combination with acetaminophen is preferred to codeine because they are less prone to cause nausea and vomiting. Intravenous therapy with morphine or fentanyl may be needed in patients with large hyphemas (grade III to IV (figure 1)) or associated traumatic injury.

●Treat nausea and prevent vomiting – Patients with nausea or vomiting require treatment with antiemetics, such as ondansetron, to prevent sudden increase in intraocular pressure caused by emesis [3].

●Dilating eye drops – For patients without narrow angle glaucoma, Cycloplegia, topically with cyclopentolate one percent (eg, Cyclogyl, Cylate, or Ocu-Pentolate), one drop, or scopolamine 0.25 percent one drop, often provides pain relief and allows for optimal examination of the posterior segment [2-4]. Dilating eye drops are contraindicated in patients with suspected open globe injury or narrow angle glaucoma [4].

●Correct coagulopathy – Patients with bleeding tendency, such as hemophilia, von Willebrand disease, or thrombocytopenia should receive appropriate treatment to restore clotting capability [5,6]. (See "Treatment of bleeding and perioperative management in hemophilia A and B" and "von Willebrand disease (VWD): Treatment of major bleeding and major surgery" and "Immune thrombocytopenia (ITP) in children: Initial management".)

If the patient is taking an anticoagulant, a decision should be made regarding appropriate interventions, including discontinuation and/or reversal of the anticoagulant effect with input from the consulting specialist. This must balance the relative benefits of anticoagulation for the individual patient. (See "Management of warfarin-associated bleeding or supratherapeutic INR" and "Management of bleeding in patients receiving direct oral anticoagulants".)

OPHTHALMOLOGIC MANAGEMENT — Once emergency management and evaluation are complete, an ophthalmologist must direct ongoing care of patients with traumatic hyphema because of the need for daily comprehensive eye examination, the risks of therapy, and the potential need for surgical intervention if medical therapy fails (table 1).

Initial therapy — Treatment of traumatic hyphema focuses on prevention of secondary hemorrhage and intraocular hypertension. Secondary hemorrhages usually result in hyphemas that are larger than the initial bleed and may increase the risk of vision loss [3,4]. (See 'Outcomes' below.)

Monitoring of intraocular pressure — Daily monitoring of intraocular pressure is a cornerstone in the management of traumatic hyphema. Uncontrolled intraocular hypertension despite maximal medical therapy may cause optic nerve damage and is an indication for surgical intervention. Uncontrolled intraocular hypertension is defined as >50 mmHg for five days, >35 mmHg for seven days or, in patients with sickle hemoglobinopathy >25 mmHg for >24 hour [4]. (See 'Surgical clot evacuation' below and "Traumatic hyphema: Clinical features and diagnosis", section on 'Predisposing conditions'.)

Limitation of activity — Although evidence of benefit is limited, limitation of activity for at least one week is a common component of ongoing treatment [7]. Observational studies and randomized trials comparing rest, head elevation, and occasional quiet ambulation in the hospital or at home have resulted in similar vision outcomes relative to strict bed rest [4,7,8]. Although evidence is lacking, reading is also restricted by many ophthalmologists because of the theoretical concern that accommodation further stresses injured blood vessels. If the hyphema is present at seven days after injury, then limitation of activity should be extended until it resolves.

Eye shield — To avoid further injury to the affected eye, an eye shield should be worn at all times until the hyphema resolves or for at least one week [2-4]. A clear rigid shield may be used in monocular patients with injury to their only eye or in young children with concern for amblyopia.

Some ophthalmologists suggest an eye patch over the shield in patients at risk for corneal blood staining (ie, patients with a large hyphema, increased intraocular pressure, or both). The purpose of the patch is to prevent ambient light from reacting with porphyrins present in the anterior chamber from the degrading hemoglobin which may cause further endothelial damage. Alternatively, an opaque shield may be used. If either an opaque shield or patch over the shield is used in a young child, the duration of application should be limited to avoid amblyopia or strabismus [4]. (See "Amblyopia in children: Classification, screening, and evaluation", section on 'Definition'.)

As opposed to an eye shield, an occlusive monocular or binocular eye patch using gauze and topical antibacterial ointment does not improve outcomes in terms of ultimate visual acuity and is not a routine practice [4,7].

Cycloplegia — For the management of pain, we suggest that patients without narrow angle glaucoma be treated with cycloplegic eye drops as follows:

●Adults – Cyclopentolate 1% (eg, Cyclogyl, Cylate, Ocu-Pentolate), one drop, three times daily or scopolamine 0.25%, one drop, twice daily

●Children (>3 years old) – Cyclopentolate 1%, one drop, two or three times daily or, to reduce frequency of eye drops, atropine 1%, one drop daily

●Infants and young children (≤3 years old) – Avoid cycloplegic eye drops for pain relief because of increased risk of side effects. In patients with traumatic hyphema, cycloplegia often provides pain relief and permits optimal examination of the posterior segment [2-4]. Long-term eye dilation also prevents the development of posterior synechiae that can result in permanent iris dysfunction. However, based upon observational studies, cycloplegia does not prevent rebleeding [9-11].

Oral analgesics, other than nonsteroidal antiinflammatory agents, may also be prescribed if cycloplegia is contraindicated or does not provide adequate pain control.

Glucocorticoid eye drops — In order to lower the risk of rebleeding, we suggest that patients with traumatic hyphema receive topical glucocorticoid eye drops rather than systemic glucocorticoids because topical steroid eye drops avoid the potential adverse effects of systemic glucocorticoid therapy (hyperactivity, sleep disturbance, hyperglycemia, systemic hypertension, and vomiting). Although evidence is lacking, topical steroids may also prevent posterior synechiae and treat iridocyclitis.

Several retrospective and unblinded prospective studies report a lower risk of rebleeding in patients who receive topical glucocorticoids (0 to 5 versus 3 to 14 percent in untreated patients) [3,4,9,11-13]. However, two small trials have failed to show a significant difference [7].

Patients receiving topical glucocorticoid drops require frequent serial examinations by an ophthalmologist to ensure no infection or corneal perforation occurs. Possible regimens include one drop of prednisolone acetate 1 percent ophthalmic drops or dexamethasone sodium phosphate 0.1 percent ophthalmic drops four times daily. Ocular hypertension may occur after more than seven days of use.

Determining sickle cell status — Individuals with sickle cell disease and those with sickle cell trait are at increased risk for complications of traumatic hyphema, including rebleeding. Thus, testing for sickle cell status is warranted for all at-risk individuals with traumatic hyphema who do not have definitive information regarding their sickle cell status. (See "Diagnosis of sickle cell disorders", section on 'Older children and adults'.)

Patients with rebleeding — Patients who have rebled warrant hospitalization for enforcement of activity restrictions, continuation of specific medical therapy, and frequent monitoring of intraocular pressure. Patients who develop intraocular hypertension that can’t be medically controlled, large persistent hyphemas (≥grade III for >10 days) (figure 1), or early corneal blood staining meet criteria for surgical clot evacuation [14]. (See 'Surgical clot evacuation' below.)

The use of antifibrinolytics for the treatment of hyphema has largely fallen out of favor. In the past, patients with traumatic hyphema who had rebleeding sometimes received systemic aminocaproic acid (ACA) or tranexamic acid therapy. Systemic antifibrinolytics do reduce the risk of rebleeding but have significant adverse effects (eg, increased risk of thrombotic events including pulmonary embolism and myocardial infarction, bradycardia, or postural hypotension with syncope) and prolong clot resorption. Furthermore, limited evidence shows no benefit in terms of final visual acuity [7].

Topical ACA provides the theoretical benefit of clot stabilization while avoiding adverse systemic effects but is not widely available. Although limited evidence suggests that topical ACA has similar benefits to systemic ACA [7], results from clinical studies that have compared topical ACA with cycloplegic drops have not shown clear evidence of reduced rebleeding [15-17].

Patients with intraocular hypertension — Topical therapy with agents that suppress aqueous flow, such as beta adrenergic blockers and carbonic anhydrase inhibitors, are frequently needed to treat increased intraocular pressure in patients with traumatic hyphema [3]. All topical agents can be absorbed systemically and may have adverse effects, therefore they should be used cautiously (table 3).

When topical therapy is inadequate, oral therapy with acetazolamide (250 mg four times daily or 500 mg extended release [ER or "sequel"] two times daily) or methazolamide (25 to 50 mg two to three times daily) may be administered.

In addition, intravenous administration of mannitol 1.5 g/kg over 45 minutes twice daily may be attempted in patients with uncontrolled intraocular hypertension despite topical therapy [12].

Carbonic anhydrase inhibitor or mannitol administration is typically avoided in patients with sickle cell disease because of the theoretical risk of sickling caused by metabolic acidosis or volume depletion. Humidified transcorneal oxygen, delivered at 1 to 3 L/min has been associated with a rapid reduction in elevated intraocular pressure in one series of three patients with sickle hemoglobinopathy and may be an alternative for such patients when topical therapy with beta adrenergic blockers does not control intraocular pressure [18].

Uncontrolled intraocular hypertension (ie, ≥50 mmHg for >5 days or, in patients with sickle hemoglobinopathy, >25 mmHg for >24 hours) despite maximal medical therapy is a potential indication for surgical anterior chamber clot evacuation. (See 'Surgical clot evacuation' below.)

Surgical clot evacuation — Approximately 5 percent of patients with traumatic hyphema require surgery. Patients with sickle hemoglobinopathy, including sickle cell trait, and bleeding tendency are more likely to meet thresholds for surgical intervention [2-4,19]. (See "Traumatic hyphema: Clinical features and diagnosis", section on 'Predisposing conditions'.)

Potential indications for surgical anterior chamber clot evacuation include [2-4]:

●Large persistent hyphemas (≥grade III for >10 days) (figure 1)

●Early corneal blood staining

●Uncontrolled intraocular pressure (ie, ≥50 mmHg for >5 days or, in patients with sickle hemoglobinopathy, >25 mmHg for >24 hours) despite maximal medical therapy

DISPOSITION — Several observational studies suggest that most patients can safely receive treatment for hyphema in the outpatient setting [3,4,12,20-22].

Hospital admission is warranted for the following patients [2-4]:

●Large hyphemas (blood occupying 50 percent or more of the anterior chamber) (figure 1)

●Hyphemas with severely elevated intraocular pressure

●Hyphemas in patients with sickle hemoglobinopathy (disease or trait)

●Patients with bleeding tendency or coagulopathy

Additional considerations regarding hospitalization include the inability to adhere to the rigorous regimen of restriction of activity, the inability to do multiple and frequent medication administration, or the inability to make daily travel to the ophthalmologist for examination [2,4].

Otherwise, for patients with traumatic hyphemas who can adhere to the treatment regimen, we suggest outpatient management. Successful outpatient management of traumatic hyphemas depends upon clear patient education. Patients and caregivers must understand the critical importance of minimizing activity, adherence to all medications, and compliance with daily ophthalmology examinations. Adherence is improved if medications and a medication schedule are provided to the patient prior to discharge.

Patients should be counselled to return for symptoms of rebleeding or elevated intraocular pressure (suddenly decreased vision and pain) or of retinal detachment (flashes, new floaters, or a shade descending over the vision).

OUTCOMES — Visual outcomes in patients with traumatic hyphemas are determined by a variety of factors as follows:

●Size of the hyphema – Grade I hyphemas or microhyphemas (figure 1) usually resolve in four to five days [3]. A final vision of 20/50 (6/18) or worse is seen in 50 to 75 percent of patients with grade III or IV hyphema (figure 1) as opposed to 10 percent or less of patients with either microhyphema or grade I hyphema [3,23,24].

●Intraocular hypertension – Intraocular hypertension can cause permanent optic atrophy. Uncontrolled elevation in intraocular pressure is an indication for surgical clot evacuation. (See 'Surgical clot evacuation' above.)

●Corneal blood staining – Corneal blood staining can occur with intraocular hypertension, large hyphemas, and when hyphemas persist. Corneal blood staining may threaten vision, especially when staining occurs in the visual axis [3,4,23,24].

●Rebleeding – Secondary hemorrhages usually result in hyphemas that are larger than the initial injury and can markedly increase the risk of vision loss in patients with microhyphema or grade I hyphema [3,4,23,24].

●Associated injury – Visual prognosis is also affected dramatically by the presence of other injuries to the vitreous, retina, and optic nerve. As many as 14 percent of hyphema patients have poor visual outcome as a result of associated sequelae such as vitreous hemorrhage, retinal detachment, or open globe [25,26]. Sympathetic ophthalmia (autoimmune-mediated inflammation of one or both eyes typically associated with penetrating eye trauma) has been reported in one case of nonpenetrating ocular injury with hyphema [27]. (See "Uveitis: Etiology, clinical manifestations, and diagnosis".)

●Preexisting conditions – Patients with preexisting sickle hemoglobinopathy or bleeding dyscrasia are at higher risk of permanent vision loss [2-4].

TRAUMATIC GLAUCOMA — Ghost cell glaucoma occurs when old red blood cells, distorted after losing their hemoglobin travel into the anterior chamber from the vitreous cavity and clog the trabecular meshwork [28]. Patients can develop late ghost cell glaucoma up to three months following hyphemas or vitreous hemorrhage. For this reason, intraocular pressure (IOP) should be checked one week after the hyphema has resolved and, if IOP is controlled, once more at four to eight weeks after the injury.

Blunt eye injury and hyphema can also place the patient at a long-term risk of developing other forms of traumatic glaucoma. Angle recession is present in up to 85 percent of patients with hyphema, thereby further elevating the risk [11,29]. Open or closed angle glaucoma may result. For this reason, all patients who have had a traumatic hyphema warrant regular measurement of intraocular pressure annually.

Traumatic glaucoma can be managed initially by eyedrops; however, it may progress to the point of requiring surgical intervention. (See "Open-angle glaucoma: Treatment" and "Angle-closure glaucoma", section on 'Secondary angle-closure glaucoma'.)

SUMMARY AND RECOMMENDATIONS

●Overview of approach – The clinician should first address life-threatening and immediate vision-threatening conditions (ie, orbital compartment syndrome or open globe) before proceeding with specific treatment of a traumatic hyphema. A rapid overview summarizes the important clinical features and initial management of traumatic hyphema (table 1). (See 'Approach' above.)

●Indications for emergency ophthalmology consultation – Patients with the following conditions warrant emergency consultation with an ophthalmologist (see 'Indications for ophthalmology consultation or referral' above):

•Orbital compartment syndrome

•An open globe

•Large hyphemas (grade III or IV (figure 1 and picture 3))

•Hyphemas associated with intraocular hypertension

•Hyphemas occurring in patients with bleeding tendency, sickle cell trait, or sickle hemoglobinopathy

●Ophthalmology referral and management – An ophthalmologist should direct ongoing care of patients with traumatic hyphema to prevent rebleeding and intraocular hypertension. If prompt consultation with an ophthalmologist is not feasible but serious associated eye injury and elevated intraocular pressure can be reliably excluded, discussion with an ophthalmologist prior to emergency department discharge is suggested. These patients warrant timely referral for complete ophthalmologic examination within 24 hours. Daily comprehensive eye examinations, including measurement of intraocular pressure, are a key component of definitive care. (See 'Ophthalmologic management' above and 'Monitoring of intraocular pressure' above.)

●Eye shield and activity restriction – Patients should wear an eye shield and restrict activity for at least one week or until the hyphema resolves if still present at one week after injury. (See 'Limitation of activity' above and 'Eye shield' above.)

●Cycloplegia – For the management of pain, we suggest that patients without narrow angle glaucoma be treated with cycloplegic eye drops (Grade 2B). Cycloplegia may also prevent the formation of posterior synechiae. Oral or intravenous analgesics, other than nonsteroidal antiinflammatory agents, may also be given if cycloplegia is contraindicated or does not provide adequate pain control. (See 'Cycloplegia' above and 'Initial management' above.)

●Glucocorticoids – We suggest that patients with traumatic hyphema receive topical glucocorticoid eye drops rather than systemic glucocorticoids to prevent rebleeding and to control inflammation (Grade 2C). Patients receiving topical glucocorticoid drops require frequent serial examinations by an ophthalmologist to ensure no infection or corneal perforation occurs. (See 'Glucocorticoid eye drops' above.)

●Patient with intraocular hypertension – Patients with traumatic hyphema and intraocular hypertension (intraocular pressure greater than 22 mmHg) require medication to decrease intraocular pressure (eg, topical beta adrenergic blocker eye drops or, except in patients with sickle cell hemoglobinopathy, carbonic anhydrase inhibiting eye drops) (table 3). (See 'Patients with intraocular hypertension' above.)

Transcorneal oxygen is an option for patients with hyphemas and sickle hemoglobinopathy who do not respond to topical therapy for intraocular hypertension and are not eligible for treatment with carbonic anhydrase inhibitors or mannitol. (See 'Patients with intraocular hypertension' above.)

●Patient with rebleeding hyphema – Patients who have rebled should be admitted to the hospital for close observation, frequent monitoring of intraocular pressure, and enforcement of limited activity. The use of antifibrinolytic agents (eg, aminocaproic acid, tranexamic acid) has largely fallen out of favor. These agents reduce the risk of rebleeding, but limited evidence shows no benefit in terms of final visual acuity. (See 'Patients with rebleeding' above.)

●Indications for surgery – Potential indications for surgical anterior chamber clot evacuation include (see 'Surgical clot evacuation' above):

•Large persistent hyphemas (≥grade III for >10 days) (figure 1)

•Early corneal blood staining

•Uncontrolled intraocular pressure (ie, ≥50 mmHg for >5 days or, in patients with sickle hemoglobinopathy, >25 mmHg for >24 hours) despite maximal medical therapy

●Disposition – Hospital admission is warranted for patients with bleeding dyscrasia, sickle cell trait, or sickle hemoglobinopathy; patients with uncontrolled intraocular hypertension on initial examination; grade III or IV hyphemas; or a hyphema that has rebled. Otherwise, patients with traumatic hyphemas who can adhere to the rigorous treatment regimen can be managed as outpatients. (See 'Disposition' above.)