This document discusses hyphema, which is blood in the anterior chamber of the eye. It defines hyphema and lists its potential causes such as trauma, medical conditions, and surgeries/medications. The document outlines methods for grading hyphema based on the amount of blood in the anterior chamber. It also discusses the clinical features, workup, potential complications like increased eye pressure, and treatment approaches like medical management with anti-inflammatory drugs and surgery if needed to prevent complications. The prognosis depends on factors like the severity of hyphema and any associated eye damage.

1. HYPHEMA
Dr Saurabh Kushwaha
Resident Ophthalmology

2. SCOPE
 Introduction
 Etiology
 Pathogenesis
 Grading
 Clinical features
 Work-up
 Complications
 Management
 Follow-up
 Prognosis

3. HYPHEMA
Blood in the anterior chamber of the eye is called hyphema

4. ETIOLOGY
 Traumatic
 Blunt trauma, penetrating injury
 Strenuous conditions
 Whooping cough, Asthma
 Blood dyscraias
 Aplastic anaemia, Leukaemia, haemophilia
 Neovascularisation (Rubeosis iridis)
 DM, BRVO, CRVO
 Miscellaneous
 Herpetic keratouvetitis
 Intraocular tumours (Retinoblastoma, iris melanoma)
 Vascular anomaly (Juvenile xanthogranuloma)
 Secondary to ocular surgery or laser
 Medications with anticoagulant properties (NSAIDs,
Aspirin, Warfarin, Clopidogrel)

5. PATHOGENESIS
 Mechanism
 Direct contusive force that causes antero-
posterior compression and equatorial expansion
leads to mechanical tearing of blood vasculature of
iris, ciliary body and TM.
 Concussive force creating rapidly rising IOP with
in the vessels resulting in rupture of vessels
 Penetrating injury leads to hyphema by
damaging the blood vessels and due to hypotony

6. GRADING
 Grade 1: < 1/3th of AC
 Grade 2: 1/3th
-1/2 of AC
 Grade 3: > ½ of AC
 Grade 4: Total

7. CLINICAL FEATURES
 Blurring of vision
 Photophobia
 Pain
 Headache
 Blood or clot or both in the AC
 Mean duration of elevated IOP is 6 days
 Duration in uncomplicated hyphema is 5-6 days

8. WORK-UP
 History
 Mechanism of injury
 Time of injury
 H/o medication (Aspirin, Warfarin)
 H/o Sickle cell disease
 H/o Coagulopathy – bleeding gums, epistaxis
 Examination
 Rule out any rupture globe or penetrating injuries
 Visual acuity
 IOP
 Slit lamp
 B scan (gently)
 CT scan - suspected orbital floor # or IOFB

9. COMPLICATIONS
 Increased IOP:
 Occlusion by clot, inflammatory cells, erythrocytic debris
 Pupillary block due collar button shaped clot
 Peripharal anterior synechiae: if hyphema > 01 week
 Optic atrophy:
 IOP > 50 mmHg for 5 days or >35 mmHg for 7 days.
 Contusion to the optic nerve
 Secondary to damage to short posterior ciliary arteries.
 Sickle cell disease even at normal IOP
 Secondary haemorrhage (rebleed): usually occurs after
day 4
 Increase in size of hyphema
 Layer of fresh RBCs over previous clot
 Change of colour from dark red to bright red.

10. COMPLICATIONS
 Corneal blood staining:
Factors which influence corneal blood staining:
 Rebleeding
 Prolonged clot duration
 Sustained increase in IOP
 Corneal endothelial dysfunction
Two main risk factors of corneal blood staining:
 IOP >25 mm of Hg
 > 6 days duration
Earliest signs:
 straw coloured discoloration of deep stroma
 presence of tiny yellow granules in posterior
1/3rd
of the cornea

11. MANAGEMENT
 Quick absorption of blood
 Prevention of complications
 Avoidance of recurrence
 Discontinuation of anti coagulation therapy
 Limiting activities
 Rest in semi upright position and head end elevation
 Patching

12. OUTPATIENT MANAGEMENT
 Walton et al:
 no associated injury
 hyphema < ½ of AC volume
 satisfactory IOP
 no blood dyscrasia
 safe home environment
 good patient compliance
 good follow up
 no time delay at presentation

13. MEDICAL MANAGEMENT
 Anti inflammatory drugs - NSAIDs
 Cycloplegics
 Topical, oral and systemic anti glaucoma drugs
 Steroids
 Anti fibrinolytic drugs - tranexamic acid, TPA,
aminocaproic acid
 Laser photocoagulation of bleeding points by
goino prism

14.  Anti fibrinolytic agents: epsilon amino caproic acid
(EACA) and Tranexamic acid are used to prevent
rebleed
 EACA (amicar) binds to lysine molecules in the
clot via lysine binding site and inhibits fibrin clot
digestion. Its dose is 100mg/kg every 4 hours to a
maximum dose of 30g/day by mouth for 5 days.
 Tranexamic acid also has similar mechanism.
 The results of various studies indicate that both
amicar and tranexamic acid have beneficial effect
on rate of secondary haemorrhage but none of
them had improved the final visual outcome.

15.  Corticosteroids:
 Stabilizes the blood-ocular barrier
 Directly inhibits fibrinolysis
 Decrease incidence of secondary haemorrhage.
 Prednisolone (0.6 mg/kg) is effective in reducing
the incidence of rebleed
 Statistical analysis indicates that coticosteroids
decreases the incidence of rebleeding without
having any effect on the long term visual outcome.
 Cycloplegics:
 Studies advocate use of Cycloplegics as they
relieve ciliary spasm and prevents formation of
PAS

16. SURGICAL MANAGEMENT
 Indications (Walton et al):
 Microscopic corneal blood staining
 IOP > 60 mm of Hg for 2 days
 IOP > 50 mm of Hg for >4 days
 IOP > 35 mm of Hg for 7 days
 Pre-existing glaucomatous optic atrophy
 Risk of corneal blood staining (e.g 4 days after the
onset of glaucoma, > ½ - total hyphema with IOP >
25mmHg > 6 days
 Risk of synechiae formation (e.g > 50% hyphema for
> 8 days
 Visual obstruction in children at risk of amblyopia
 Sickle cell disease if IOP >25 mm of Hg for >24 hours
or spikes repeatedly >30 mm of Hg

17. SURGICAL MANAGEMENT
 Simple paracentesis - allow the clot to retract
 Irrigation and aspiration
 Through a large limbal incision: manual expression,
cryoextraction, ultrasonic emulsification
 Clot expression and limbal delivery is usually
advocated 4 to 7 days after the initial injury, when clot
consolidation and retraction is at its peak.
 Clot irrigation with trabeculectomy is reserved for
total hyphema

18. FOLLOW-UP
 Hospitalised patient - Daily V/A, IOP, Slit lamp exam
 After discharge - next follow up after 2-3 days
 1 - 2 weeks as per severity
 After 4 weeks - gonioscopy and fundus exam

19. PROGNOSIS
 Determinants:
 Amount of associated damage to other ocular
structures like choroidal rupture, macular scarring
 Secondary hemorrahge (rebleed)
 Complications of Glaucoma, corneal blood
staining or optic atrophy
 Recovery of V/A is good in approx 75% of patients:
 Hyphema <1/3 of AC -- V/A 6/12 or better in
80% cases
 Hyphema >1/2 - 2/3 of AC -- V/A 6/12 or better
in 60% cases
 Hyphema Grade IV -- V/A 6/12 or better in 35%
cases

20. THANK YOU