Traumatic Hyphaema

Traumatic Hyphaema is the accumulation of blood in the anterior chamber of eye following trauma. Trauma is the most common cause of hyphaema. Traumatic hyphaema may occur following both blunt and penetrating injuries. A ruptured iris root blood vessel generally causes bleeding. Hyphaema may affect vision by blocking the visual axis. Hyphaema may also be a sign of associated damage to intraocular tissues. Damage to intraocular tissues may be the cause of poor vision in spite of resolution of hyphaema.

Following conditions may produce spontaneous hyphaema

• Rubeosis iridis
• Retinoblastoma
• Juvenile xanthogranuloma
• Haemophilia
• Leukaemia
• Anticoagulant therapy

Traumatic hyphaema predominantly affect males in the age group below twenty years. Lack of protective eyewear in sports is a predisposing factor. Use of polycarbonate safety lenses may decrease the incidence of traumatic hyphaema.

Though traumatic hyphaema often resolves without any sequelae, the potential for visual loss should not be underestimated.

References

Roy Hampton, Fraunfelder Frederick W, Fraunfelder Frederick T, Tindall Renee, Jensvold Bree. Roy and Fraunfelder’s Current Ocular Therapy Sixth Edition. Elsevier Inc. 2008. P 311- 314.

Nelson Leonard B, Olitsky Scott E. Harley’s Pediatric Ophthalmology Fifth Edition. Lippincott Williams & Wilkins 2005. P 516- 518.

Wilson M Edward, Saunders Richard A, Trivedi Rupal H. Pediatric Ophthalmology- Current Thought and a Practical Guide. Springer- Verlag Berlin Heidelberg. P 472- 473.

Trattler William, Kaiser Peter K, Friedman Neil J. Review of Ophthalmology Second Edition. Elsevier Inc. 2012. P 273- 274.

Adams James G, Barton Eric D, Collings Jamie, DeBlieux Peter M C, Gisondi Michael A, Nadel Eric S. Emergency Medicine – Clinical Essentials Second Edition. Saunders, an imprint of Elsevier Inc. 2013. P 223- 224.

http://eyewiki.aao.org/Hyphema

https://www.aao.org/focalpointssnippetdetail.aspx?id=248e1998-310a-4f6a-b6a9-b470c60c9773

https://www.ncbi.nlm.nih.gov/pubmed/12161209

https://emedicine.medscape.com/article/1190165-overview

Symptoms may be

• Pain in the eye.
• Diminution of vision
• Photophobia
• Drowsiness, especially in children

Blunt trauma is the most common cause of hyphaema. Compressive force to the eye may damage iris, ciliary body, trabecular meshwork and their associated blood vessels. Shearing forces due to injury may tear away the blood vessels.

Iatrogenic hyphaema may occur during intra-operative procedures or may develop post-operatively. Hyphaema may also develop following ocular laser procedure.

Spontaneous hyphaema may be secondary to neo-vascularisation, ocular neoplasms, uveitis or vascular anomalies.

Clinical history and examination may help in identification of most hyphaemas. Upright posture of patient at an angle of 30° allows the hyphaema to settle at a fluid level. Size and shape of hyphaema is recorded daily, so as to assess its resolution or secondary haemorrhage, if it occurs. Daily assessment of visual acuity and pupillary reactions help in assessment of progress of medical management. Applanation tonometry to record intraocular pressure is deferred, unless elevated intraocular pressure is suspected. Fundus examination is also postponed till the media is clear, barring few exceptions. B- Scan can be done, if retinal detachment is suspected.

Based on the amount of blood present in the anterior chamber at the time of presentation, Hyphaema is classified into grades.

The grades are:

• Microscopic: Circulation of red blood cells only, no layering.
• Grade I: Less than 33% of anterior chamber is filled with blood.
• Grade II: 33%- 50% of anterior chamber is filled with blood.
• Grade III: 50%- 95% of anterior chamber is filled with blood.
• Grade IV: 100% of anterior chamber is filled with blood (Total or ‘Eight ball’ hyphaema).

Total hyphaema is differentiated from eight- ball hyphaema by retention of bright red colour, which indicates aqueous circulation. In ‘Eight- ball’ hyphaema, blood clots and take on black or purple colour because of impaired aqueous circulation and deoxygenation, which prevents resorption.

Differential diagnosis

Traumatic hyphaema should be differentiated from hyphaema due to causes such as

• Neovascularisation
• Neoplasm
• Ocular surgery
• Treatment with lasers
• Infections/ Inflammatory conditions
• Vascular anomalies

There is diversity of opinion regarding how to manage patients with traumatic hyphaema. Proper information of the current status and serious nature of injury to eye is the first step of management.

Supportive therapy:

Elevation of head of patient helps in settling of the hyphaema due to gravity. This may help in clearing the visual axis to improve the vision and allow fundus examination. Eye patching with metal shield protects the eye.

Inpatient care of patient has been the standard care for many years. It helps in easy monitoring and administration of medicines.

Some recent studies have shown comparable outcomes with outpatient daily visits. Outpatient visit is preferred by patient and their family and is recommended in compliant patients.

Inpatient management is still advisable for patients who are at increased risk of secondary bleeding, glaucoma or possible noncompliance.

Medical therapy:

• Anti-glaucoma drugs: Elevated intraocular pressure is common after injury to eye and may lead to corneal blood staining. Drugs like topical beta-adrenergic antagonists are usually the first choice. Hyperosmotic agents and topical/systemic carbonic anhydrase inhibitors may also be used. Patients with sickle cell anaemia require intensive treatment because sickle cells can block the angle of anterior chamber. This may lead to elevation of intraocular pressure.
• Corticosteroids: Corticosteroids may reduce the risk of secondary haemorrhage by inhibiting fibrinolysis and stabilising blood-ocular barrier. Topical corticosteroids have shown to reduce intraocular inflammation and may prevent re-bleeding. It reduces iritis and prevent formation of posterior synechia in adults.
• Antifibrinolytics: To reduce re-bleeding, topical and systemic antifibrinolytics such as tranexamic acid may be used. These inhibit fibrinolysis and stabilise blood clot.

Topical cycloplegic agents are useful in patients with significant ciliary spasm or photophobia.

Surgical therapy:

Medical therapy is preferable for initial four days if rise in intraocular pressure is well controlled and there is no blood staining of cornea. Surgical evacuation of blood may be required in certain group of cases.

Indications for surgical evacuation of blood clot in hyphaema:

Elevated intraocular pressure (IOP), unresponsive to medical therapy:

• IOP > 50 mm of Hg for 5 days.
• IOP > 35 mm of Hg for 7 days.
• IOP > 25 mm of Hg for 1 day in patients with sickle cell disease or trait or pre-existing glaucoma.

Corneal blood staining:

• At the first sign of blood staining, regardless of IOP or grade of hyphaema.
• IOP > 25 and total hyphaema to prevent blood staining.

Prolonged duration of clot:

• Persistent total hyphaema > 5 days.
• Persistent small hyphaema > 10 days.

Prognosis:

Prognosis for recovery of vision is related to damage to other ocular structures, development of glaucoma, corneal blood staining, re-bleeding and optic atrophy. Patients with traumatic hyphaema requires follow up for assessment of development of any complications.

Hyphaema may produce complications such as

• Increased intraocular pressure
• Corneal blood staining
• Formation of peripheral anterior synechia
• Secondary haemorrhage
• Optic atrophy.