I’m Ed Smith, a Roseville personal injury lawyer. Blunt trauma to the eye often results in bleeding into the anterior chamber, which is called a traumatic hyphema. Although the blood usually clears out from the anterior chamber, there can be complications of this condition. Because these complications can threaten the vision, it is important to follow hyphema patients very carefully.
Most hyphemas occur in males with a 3:1 ratio.
Seventy percent of patients are under the age of 20 at the time of their injury. They can be caused by many things, including fists, sticks, rocks and BB guns. Sports injuries make up 60 percent of traumatic hyphemas. There are about 17-20 per 100,000 people who get a traumatic hyphema each year.
Microscopic hyphemas occur when there are circulating red blood cells in the anterior chamber that don’t result in the gross collection of visible blood. The major complication of this type of injury is a rebleeding of the hyphema, which happens about seven percent of the time.
Blunt trauma to the eye can cause stretching of the limbal tissues, posterior displacement of the lens or posterior placement of the iris, resulting in acute elevation of the pressure within the eye called increased intraocular pressure. This causes tearing of the tissues near the angle of the anterior chamber with subsequent bleeding. Most hyphemas result from tears in the anterior part of the ciliary body with disruption of the major arteries circling the anterior chamber. About 15 percent of hyphemas result from rupture of the iris vessels.
There are other non-injurious conditions that result in a hyphema. Spontaneous hyphemas from the iris rarely occur unless the patient has a bleeding disorder.
Recession of the angle, or a separation between the circular fibers and the longitudinal fibers of the ciliary muscle is the most important finding in a traumatic hyphema. The amount of recession of the angle doesn’t necessarily correlate with the size of the hyphema or the degree of increased intraocular pressure. The incidence of recession of the angle is about 30-85 percent. More extensive recession of the angle is associated with a high incidence of late onset glaucoma. A cleft with separation of the scleral spur with the ciliary body attachments may also occur with a hyphema.
Traumatic iritis is a common finding after an acute hyphema. Pigment may be liberated from the iris, resulting in dusting of the pigment and increased pigmentation of the trabecular meshwork. Iris atrophy can also occur although this is less common.
Traumatic mydriasis occurs in about ten percent of cases secondary to paralysis of the sphincter muscle and tearing of the iris. Severe traumatic iritis can also cause miosis of the eye. Corneal abrasions are also common after blunt trauma to the eye and the possibility of a globe rupture must always be kept in mind. Rupture of the eye can be seen as chemosis, hypotonia, and subconjunctival hemorrhage as seen on an ophthalmological examination. The endothelium of the cornea can be damaged by blunt trauma, and this can be seen as having corneal edema and staining of the cornea. Cataract formation can happen in 5-15 percent of cases secondary to the blunt trauma to the eye.
Damage to the posterior segment of the eye can show up as reduced vision after the blood has cleared from the traumatic hyphema. Significant retinal edema, vitreous hemorrhage and choroidal rupture can occur in as many as 33 percent of cases of traumatic hyphema. Optic atrophy can develop from direct trauma to the optic nerve or after marked elevation of the intraocular pressure. These can result in irretrievable visual loss in patients after sustaining a traumatic hyphema.
Bleeding from the injured vessel in a traumatic hyphema can stop because of an increase in the intraocular pressure, from vascular vasospasm, or from the formation of a platelet clot in the anterior chamber. Maximum clot integrity is achieved after 4-7 days following the injury. Eventually, however, plasminogen is converted into plasmin and the plasmin breaks down the fibrin, breaking up the blood clot.
Free blood cells and fibrin degradation products in the anterior chamber can clear out through outflow pathways in the anterior chamber. Absorption by the vasculature of the iris may also play a role in clearing out the clot.
History and Physical Examination
Patients who have sustained a hyphema complain of decreased vision and pain in the eye. Many times, children are somnolent after this type of injury. Both blunt and penetrating trauma can commonly cause a hyphema but have different associated eye problems. Particular attention must be paid to any history of bleeding disorders, kidney disease, liver disease, and recent anticoagulation use.
A complete eye exam is required of any patient who has a hyphema. Blunt rupture of the globe is the most important associated clinical finding to be ruled out and all patients should be considered to have a ruptured globe until proven otherwise.
Hyphemas should be described in detail so they can be compared to findings at a later date. A hyphema can be described according to its height in the anterior chamber in millimeters or the percentage of anterior chamber filled with blood. Clotted blood should be distinguished between unclotted blood. Free circulating blood cells should be quantified as 1+ to 4+ as much as possible. If the eye is examined early enough, the exact location of the bleeding can be determined. Rebleeding can be seen as bright red blood layered over a darker clot of blood.
The status of the hyphema, vision, and increased intraocular pressure should be documented at every follow up examination. A slit lamp is usually used to identify the features of the hyphema. Corneal blood staining can be seen using the slit lamp.
Lab tests for sickle cell disease should be done on every African-American patient because of the high risk for the disease in this population. Liver function tests, a Protime, platelet counts and other bleeding tests should be done to make sure there is no bleeding problem adding to the hyphema.
Treatment of Traumatic Hyphema
Studies do not show a statistically significant rate of rebleeding if the patient is hospitalized or sent home after the injury. Advantages of putting them in the hospital is that it is easier to do follow up examinations and confirm medical compliance if they are kept in the hospital. Most patients, however, prefer to be treated at home.
Bed rest with bilateral patching may decrease the rate of rebleeding in hyphema patients. The hyphema tends to resorb more quickly if the patient is at bedrest but the rate of rebleeding makes no difference. Patching both eyes may increase the rate of anxiety, especially in small children. Restrictions on reading does not appear to make any difference in complication rates. Sedation is rarely required when the patient is allowed mild activity. Metal shields are a good idea as is elevating the head to about 30 degrees, which enhances the dependent settling of the blood in the anterior chamber and allows for better visualization of the posterior part of the eye.
Treatment usually involves giving cycloplegics and miotic agents, as well as antifibrolytic agents. Estrogens and corticosteroids have also been suggested. Few have been found to be helpful so they are less often used at this time. Aspirin and other blood thinners should be avoided. Cycloplegics may enhance patient comfort, especially if there is traumatic iritis present. Miotics are avoided as they tend to increase inflammation in the eye.
Treatment with Steroids
Topical steroids are used to prevent traumatic iritis in the setting of a traumatic hyphema. Systemic steroids tend to be more controversial. Oral prednisone may decrease the rate of rebleeding of the hyphema.
Most doctors favor treating hyphema patients in the hospital. The patients receive a metal shield to protect the eye and are permitted moderate activity as long as the head of the bed is kept at 30 degrees. Aspirin products are avoided. Topical medications include atropine and topical steroids. Aminocaproic acid is given every 4 hours for 5 days. If there is no sign of rebleeding after two days, the patient can be allowed to go home. Daily follow up is recommended for a total of five days.
Five percent of hyphema patients will require surgery. This is especially true if the intraocular pressure is high so as to avoid damage to the optic nerve. If there is corneal blood staining, early surgical intervention is required to remove blood from the anterior chamber and to reduce the intraocular pressure. Patients with a total or near-total hyphema also require surgery to remove the blood. Patients with large clots that last for up to 10 days may also be candidates for surgery. Total hyphemas that haven’t resolved after 5 days should be removed.
Some of the main complications of a traumatic hyphema include rebleeding in 3.5-38 percent of patients. This usually occurs between 2 and 5 days after the initial injury. Rebleeding is associated with a poorer prognosis because there can be a total hyphema or increased intraocular pressure in these patients. Aspirin use is associated with rebleeding and should be avoided.
Glaucoma is another complication of a hyphema. Topical beta blockers and oral carbonic anhydrase inhibitors are the mainstays of therapy for glaucoma secondary to a hyphema. Oral and IV hyperosmotic agents are used for spikes in the intraocular pressure. More aggressive treatment is needed for those with sickle cell disease or in those who have other types of bleeding disorders.
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