April 18, 2014

Hyphema

Hyphema is blood in the anterior chamber of the eye. It may appear as a reddish tinge, or it may appear as a small pool of blood at the bottom of the iris or in the cornea.

  • Grade 1 – less than 1/3rd of anterior chamber
  • Grade 2 – 1/3 to 1/2 of anterior chamber
  • Grade 3 -greater than 1/2 but less than grade 4 (see below)
  • Grade 4 – Anterior chamber completely filled, also known as 8 ball hyphen

CLICK THE PLAYER BELOW TO HEAR THE PODCAST

Causes:

  • Blunt trauma-most common cause, generally the vessels that join to iris to the eye
  • Spontaneous
  • Lymphoma
  • Leukemia
  • Child abuse
  • Post surgical

Clinical Questions

Does it matter how much blood accumulates?
Yes a large bleed is worse than a micro bleed but both are really sentinel events for the potentially worse re-bleed. It is the re-bleed that carries a higher risk of blindness.
How do you prevent the re-bleed?
  • Bed rest or light activity: To prevent a re-bleed into the anterior chamber which may cause obstruction of vision, or a rise in intraocular pressure. No reading – movement of the eye can precipitate loosening or loss of clot.
  • Elevation of the head of the bed: Approximately 30 – 45 degrees (so that the hyphema can settle out inferiorly and avoid obstruction of vision, as well as to facilitate resolution) laying flat will not cause any permanent deficit though will cause difficulty seeing or blurry vision.
  • Wearing of an eye shield: This prevents accidental rubbing of the eyes, which can precipitate a re-bleed.  DO NOT APPLY PRESSURE TO EYE. Use a metallic Fox Shield or paper cup
  • Avoidance of NSAIDS: Aspirin or ibuprofen (which thin the blood and increase the risk of a re-bleed) – instead, acetaminophen can be used for pain control.
  • Sickle Cell Screen: If African American or Mediterranean check for sickle cell disease, patients are at increased risk even if just sickle cell trait. MUST KNOW THIS IS GOING TO GIVE DIAMOX AS IT CAN CAUSE SICKLING.

Medical Treatment

  •  Aminocaproic acid -  to reduce further bleeding (decreases the likelihood of a re-bleed) - Aminocaproic acid (also known as Amicar,) is a derivative and analogue of the amino acidlysine, which makes it an effective inhibitor for proteolytic enzymes like plasmin, the enzyme responsible for fibrinolysis. For this reason it is effective in treatment of certain bleeding disorders
  • Cycloplegic eye drops - to dilate and rest the pupil. The best is atropine because it completely paralyzes the movement of the iris, where other cyclopleigic drops allow for some movement.
  • Check Intraocular Pressure:
    • Blood can clog the trabecular meshwork and cause the IOP to become dangerously high
    • Elevated pressure can cause blood cells to be forced into the eye causing staining of the cornea

Elevated Intraocular Pressure Treatment

  • Timolol – B-blocker that is a aqueous suppressant, quick acting and few side effects
  • Topical carbonic anhydrase inhibitor -Inhibition of carbonic anhydrase in the ciliary processes of the eye decreases aqueous humor secretion and thus lowers the intraocular pressure in the anterior chamber
    • Brinzolamide (trade name Azopt)
    • Acetazolamide  (trade name Diamox) - can be given IV in extreme cases
    • Dorzolamide (trade name Trusopt)
  • Alpha 2 agonists- acts via decreasing synthesis of aqueous humor, and increasing the amount that drains from the eye through uveoscleral outflow
    • Brimonidine (trade names Alphagan and Alphagan-P)
    • Apraclonidine (trade name Iopidine)
  •  VERY RARELY- Paracentesis may be preformed

Additional Resources

Written Summary:  Justin Arambasick MD  Akron General  Medical Center

 

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About Rob Orman

Deceptively tall.
Podcaster to the stars, father of many, lover of few

Comments

  1. How good is this? Hyphema ed

  2. Hi Rob
    Nice work. Great to hear such a logical way to approach hyphema.
    Aminocaproic acid is not commonly available in most places. But since CRASH2 IV tranexamic acid is everywhere -- so is this as good? Seemed to be well tolerated in the trauma patients ?

  3. Rob,

    I listened to this podcast in 2011 but reminded of it yesterday at our hospital’s rounds. Case presentation of hyphema in patient on pradaxa and ASA. Hematology suggested TXA. As per Casey’s comment, I don’t know if I’ve ever seen Amicar in my hospital. TXA readily available.
    Bleeding stopped. But the antiplatelet/anticoagulant meds were also stopped.

    -Elisha

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