THERAPEUTIC FORUM

Strike a Good, Hard Blow
Against Traumatic Hyphema

by Christopher J. Quinn, O.D.

Blunt trauma to the eye can result in a host of sequelae to both the orbit and the globe itself. When blunt traumatic force is directed to the globe, the interior structures of the eye are subject to traumatic injury. Traumatic injury to the vascular uveal tissue may result in disruption of the uveal blood vessels and intraocular bleeding.

Blunt traumatic injuries with significant force to the anterior segment may result in intraocular bleeding and specifically, traumatic hyphema.

A traumatic hyphema occurs most often when traumatic forces are directed to the iris root. The iris root can tear and separate from the anterior wall of the ciliary body, resulting in broken blood vessels and bleeding. As blood leaks into the anterior chamber, red blood cells accumulate and layer in the inferior portion, forming the hyphema. Gonioscopy will often reveal the small clot at the site of the traumatic injury that resulted in the bleed.

Patients with traumatic hyphema often experience a painless, but significant, reduction in visual acuity as a result of blood in the anterior chamber.

Clinical examination of the anterior chamber reveals layered accumulation of blood and a turbid aqueous with 4+ circulating red blood cells. Changes in the patient's posture may cause the red blood cells in the layered hyphema to mix with aqueous, leading to further reduction in visual acuity.

Typically within 3-7 days after injury, the iris blood vessels slowly resorb the blood in the anterior chamber, and the traumatic hyphema spontaneously resolves. About five days later, however, there is lysis of the clot that resulted from the original injury. As the clot dissolves, patients are prone to rebleeding and a recurrence of their hyphema.

The two most important aspects of managing traumatic hyphema are to reassure the patient and to monitor IOP. Patients with traumatic hyphema are susceptible to IOP elevations.

If the pressure rises significantly even for a short time, blood staining of the cornea may result as the vessels force red blood cells into the corneal stroma and endothelium. Even mild pressure spikes may result in corneal blood staining. You must manage IOP with aqueous suppressants, and closely monitor these patients until the hyphema resolves and the risk of rebleed passes.

In some cases, you may need to prescribe antifibrinolytic agents such as aminocaproic acid (Amicar) to prevent rebleeding of traumatic hyphema. A dosage of 50mg/kg of Amicar, taken every four hours for five days, has been shown to reduce a patient's risk for rebleeding in traumatic hyphema. A topical formulation of Amicar also appears effective in preventing rebleeds.

Amicar is best reserved for cases in which there is significant risk of rebleed. These include patients who have a total hyphema (the entire anterior chamber filled with blood) or patients on anticoagulant therapy.

In some cases of persistent total hyphema and persistently elevated IOP, surgical evacuation of the hyphema may be indicated.