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Hyphema

Hyphema

Definition

A hyphema is an accumulation of blood in the front (anterior) chamber of the eye. It is usually caused by blunt eye trauma.

Description

The anterior chamber (AC) is located behind the front of the eye. The AC is filled with a fluid called aqueous humor. This fluid helps form a cushion for the eye and provides an important route for nutrient and waste transport. Contusive forces from high velocity projectiles (approximately 34% of emergency room cases) such as a rock, crab apples, ice balls, badminton birds, and bungee cords can tear local blood vessels in the eye. Blunt impact from a basketball or racketball accounts for about 62% of cases. Tearing a small blood vessel can cause seepage of blood into a visible layer portion of the AC, causing the affected person to have red eye.

Causes and symptoms

Hyphema is caused by blunt, projectile, or explosion (about 4% of cases) injuries. These injuries cause a local blood vessel in the eye to tear, filling the front portion of the AC with blood. The initial complaint is a dramatic decrease in vision that eventually gets better as blood seeps towards the back of the eye. Patients will have extreme pain, an increase in intraocular pressure (the pressure inside the eye), and nausea. Patients usually will show a red eye and a recent history of trauma. Patients are vulnerable to more bleeding three to five days post injury.

Diagnosis

All persons with hyphema must be examined by an ophthalmologist (a physician who specializes in the medical and surgical care of the eye). Usually the clinician will use an ophthalmoscope to visualize the internal structures and damage. In some cases there may be small microscopic bleeds that may form clots (microhyphema) and require specialized instrumentation (a slit lamp) for visualization.

Treatment

Bloodthinners, such as aspirin and nonsteroidal anti-inflammatory drugs, should be avoided. In most cases the affected person can be medically managed on an outpatient basis. The eye should be shielded, but not patched. The patient should be placed at bed rest with the head elevated 45°. This position allows blood to leave the AC allowing for better vision. Several studies suggest administering medications (aminocaproic acid) that stabilize clot formation, reducing the possibility of increased bleeding.

Prognosis

The outcome depends on the severity of the trauma. Most cases progress well with conservative treatment. Some cases may develop an increase in the pressure within the eye (glaucoma). If this develops the hyphema must be surgically removed by an ophthalmologist. In patients who have a preexisting blood disorder, surgical evacuation should be considered to prevent damage to the optic nerve (the nerve that transmits impulses for processing in the brain).

Prevention

The American Academy of Ophthalmology recommends special eyewear made of polycarbonate lenses when at risk of eye injury. This type of lens has sufficient impact resistance.

Resources

BOOKS

Behrman, Richard E., et al, editors. Nelson Textbook of Pediatrics. 16th ed. W. B. Saunders Company, 2000.

Yanoff, Myron, et al, editors. Ophthalmology. Mosby International Ltd., 1999.

KEY TERMS

Microhyphema Small bleed in the anterior chamber of the eye.

Ophthalmologist A physician with specialized training in the medical and surgical treatment of eye diseases.

Optic Nerve A cranial nerve that carries visual impulses to the brain for processing

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