title: Management of traumatic hyphema.
abstract: Hyphema (blood in the anterior chamber) can occur after blunt or lacerating trauma, after intraocular surgery, spontaneously (e.g., in conditions such as rubeosis iridis, juvenile xanthogranuloma, iris melanoma, myotonic dystrophy, keratouveitis (e.g., herpes zoster), leukemia, hemophilia, von Willebrand disease, and in association with the use of substances that alter platelet or thrombin function (e.g., ethanol, aspirin, warfarin). The purpose of this review is to consider the management of hyphemas that occur after closed globe trauma. Complications of traumatic hyphema include increased intraocular pressure, peripheral anterior synechiae, optic atrophy, corneal bloodstaining, secondary hemorrhage, and accommodative impairment. The reported incidence of secondary anterior chamber hemorrhage, that is, rebleeding, in the setting of traumatic hyphema ranges from 0% to 38%. The risk of secondary hemorrhage may be higher in African-Americans than in whites. Secondary hemorrhage is generally thought to convey a worse visual prognosis, although the outcome may depend more directly on the size of the hyphema and the severity of associated ocular injuries. Some issues involved in managing a patient with hyphema are: use of various medications (e.g., cycloplegics, systemic or topical steroids, antifibrinolytic agents, analgesics, and antiglaucoma medications); the patient's activity level; use of a patch and shield; outpatient vs. inpatient management; and medical vs. surgical management. Special considerations obtain in managing children, patients with hemoglobin S, and patients with hemophilia. It is important to identify and treat associated ocular injuries, which often accompany traumatic hyphema. We consider each of these management issues and refer to the pertinent literature in formulating the following recommendations. We advise routine use of topical cycloplegics and corticosteroids, systemic antifibrinolytic agents or corticosteroids, and a rigid shield. We recommend activity restriction (quiet ambulation) and interdiction of non-steroidal anti-inflammatory agents. If there is no concern regarding compliance (with medication use or activity restrictions), follow-up, or increased risk for complications (e.g., history of sickle cell disease, hemophilia), outpatient management can be offered. Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.
authors.affiliation: Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, New Jersey 01701-1709, USA.
authors.forename: William
authors.initials: W
authors.lastname: Walton
authors.forename: Stanley
authors.initials: S
authors.lastname: Von Hagen
authors.forename: Ruben
authors.initials: R
authors.lastname: Grigorian
authors.forename: Marco
authors.initials: M
authors.lastname: Zarbin
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000553:Ambulatory Care; D000755:Anemia, Sickle Cell / Q000150:complications; D000867:Anterior Chamber / Q000293:injuries*; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D001510:Bed Rest; D003316:Corneal Diseases / Q000209:etiology; D006801:Humans; D006988:Hyphema / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D015201:Meta-Analysis as Topic; D009798:Ocular Hypertension / Q000209:etiology; D010859:Pigmentation Disorders / Q000209:etiology; D012008:Recurrence; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000150:complications*
chemical_list: D000305:Adrenal Cortex Hormones; D000933:Antifibrinolytic Agents