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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.
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. 
Fig; Bleeding from the ciliary body
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 
•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 ½ to less than total of the anterior chamber 
•Grade IV: Total clotted blood, often referred to as blackball or 8-ball hyphaema 
Hyphaemas can be graded from I-IV in the following manner:
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

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Hyphema

  • 1. DEPT. OF OPTHALMOLOGY SHER-E-BANGLA MEDICAL COLLEGE HOSPITAL, BARISAL. HYPHEMA DR. MD. NURUL ISLAM DO STUDENT SESSION – JULY, 2013 12-11-2013
  • 2. Definition: Blood in the anterior chamber of eye is called Hyphema.
  • 3. 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. Fig; Bleeding from the ciliary body
  • 4. 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
  • 5. 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.)
  • 6. 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
  • 7. Grading •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 ½ to less than total of the anterior chamber •Grade IV: Total clotted blood, often referred to as blackball or 8-ball hyphaema Hyphaemas can be graded from I-IV in the following manner:
  • 9. 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.
  • 10. 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.
  • 11. 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
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. Complications: •Obstruction of trabecular meshwork with associated IOP elevation •Peripheral anterior synechiae (PAS) •Posterior synechiae •Corneal blood staining •Rebleeding •Pupillary block •Amblyopia (pediatric patients)
  • 17. 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
  • 18. 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
  • 19. 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/