DEPT.

OF OPTHALMOLOGY
SHER-E-BANGLA MEDICAL COLLEGE HOSPITAL, BARISAL.

HYPHEMA
DR. MD. NURUL ISLAM
DO STUDENT
SESSION JULY, 2013
12-11-2013
Definition:
Blood in the anterior chamber of eye is called
Hyphema.
Fig; Bleeding from the ciliary body

Pathophysiology:
Compressive force to the globe or trauma can result
in injury to the iris, ciliary body, trabecular
meshwork, and their associated vasculature. The
shearing forces from the injury can tear these vessels
and result in the accumulation of blood cells within
the anterior chamber.
 Classification
Etiological:
1. Traumatic hyphaema
- most commonly blunt trauma
2. Strenuous conditions
- Whooping cough, Asthma etc.
3. Blood dyscrasia
- Aplastic anaemia, leukemia, hemophilia,
von Willebrand disease etc.
4. Neovascularization (Rubeosis iridis)
- Diabetes mellitus, CRVO, BRVO
 Classification
Etiological:
5. Miscellaneous
-Herpetic keratouveitis
- Intraocular tumors (retinoblastoma, iris
melanoma etc.)
- Vascular anomaly - juvenile xanthogranuloma (JXG)
- Secondary to ocular surgery or laser
-Medications with anticoagulant properties
(aspirin, NSAIDs, warfarin or clopidogrel etc.)
 Classification

Clinical:
1. Mild or simple hyphema (2-3mm)
2. Moderate hyphema (3-5mm)
3. Severe hyphema more than half of A/C
4. Total hyphema A/C full of blood
 Grading
Hyphaemas can be graded from I-IV in the following manner:

Grade 0: No visible layering, but red

blood cells within the anterior
chamber (microhyphaema)
Grade I: Layered blood occupying less
than 1/3 of the anterior chamber
Grade II: Blood filling 1/3 to 1/2 of
the anterior chamber
Grade III: Layered blood filling to
less than total of the anterior
chamber
Grade IV: Total clotted blood, often
referred to as blackball or 8-ball
hyphaema
Presentation
 Presentation
Symptoms:
Symptoms can be variable depending on the
etiology. Typically patients complain of blurry
vision, pain, headahce, photophobia, H/O
trauma.
Signs:
Blood or clot or both in the AC, usually visible
without a slit lamp.
 Examinations/Work-up

1. History:
Detailed including -
-Mechanism of injury
- Time of injury with time of visual loss(if any)
- H/O medications (aspirin, warfarin etc.)
- H/O Sickle cell disease (familial or personal?)
-Any H/O coagulopathy- bleeding gums,
epistaxis etc.
 Examinations/Work-up

2. Ocular examinations:
- Rule out any rupture globe or penetrating
injuries
- Visual acuity
- IOP
- Slit lamp examination
- B-scan (gently) if A/C filled with blood
- CT may be done if suspected orbital fracture or
IOFB
Management
Principles of management:
1.Quick absorption of blood (rest of the pt. rest
of the eye)
2. Prevention of complication (aggressive Rx for
children especially those at risk of amblyopia)
3. Avoidance of recurrence
4. Discontinuation any anticoagulation
medication
5.Limiting activities, rest with semi-upright
posture including during sleeping
Treatment: (Medical)
1. Sedation or complete bed rest with limited
activites.
2. Cycloplegics; Atropine 1% E/D
3. Anti inflamatoty
- Steroids, mild NSAIDs
4. Ocular hypotensive agents in case of IOP (if
bilateral systemic should be added)
5. Place shield or patch over involved eye or
both eyes (controversial)
6. Rx of the cause
Treatment: (Surgical)
- A/C paracentes with irrigation and aspiration
Indications:
- Corneal blood staining
- Significant visual deterioration
- to prevent optic atrophy
(IOP >60 mm Hg for >48 hours, despite maximal
medical therapy)
- to prevent peripheral anterior synechiae (PAS)
(Hyphema <50% for 8 days)
- IOP >25 mm Hg with total hyphema for >5 days
- IOP 24 mm Hg for >24 hours (or any transient
increase in IOP >30 mm Hg) in sickle cell disease/trait
patients
Complications:
Obstruction of trabecular meshwork with associated
IOP elevation
Peripheral anterior synechiae (PAS)
Posterior synechiae
Corneal blood staining
Rebleeding
Pupillary block
Amblyopia (pediatric patients)
Follow-Up:
1. Hospitalized pt. should be monitored everyday for
V/A, IOP and slit-lamp examinations
2. After discharge next follow-up would be after 2-3
days
3. Then several days to 1 week according to severity
4. After 4 weeks Gonioscopy and detailed fundus
examination is must for all patients
Prognosis:
Success of hyphaema Rx is judged by the recovery
of visual acuity, it is good in approximately 75% of
patients and in those-
Hyphema <1/3 of AC - - VA 6/12 or better in 80% cases
Hyphema <1/2-2/3 of AC - - VA 6/12 or better in 60%
cases
Hyphema <1/3 of AC - - VA 6/12 or better in 80% cases
while only approximately 35% of cases with an initially
total or a Grade 4 hyphema have good visual results
References:
1. Lecture notes - Professor Dr. Md. Shahidul Alam FCPS
Head of the Dept. of Opthalmology,
Sher-E-Bangla Medical College Hospital, Barisal.
2. Jack J Kanski Brad Bowling
Clinical Ophthalmology A SYSTEMATIC APPROACH 7th Edition
3. The Wills Eye Manual
Office and Emergency Room Diagnosis and Treatment of Eye Disease, 5th Edition
4. http://eyewiki.aao.org/
5. http://www.medscape.com/
THANK YOU