Traumatic Hyphaema

Blood in the anterior chamber after blunt or penetrating injury, from rupture of iris or ciliary body vessels. Typically young males (sports, fireworks, projectiles).

• Grading by height of blood: microscopic (red cells only), grade I (less than one third of the chamber), grade II (one third to one half), grade III (one half to less than total), grade IV (total, "eight ball", blackened by clot).
• Complications: rebleeding (secondary haemorrhage, typically 2 to 5 days after injury, 3 to 35 percent, worse than initial bleed), raised intraocular pressure (about 30 percent), corneal blood staining (with total hyphaema and high pressure), optic atrophy (sustained pressure), angle recession glaucoma, peripheral anterior synechiae, cataract.
• Sickle cell disease and trait: sickled red cells clog the trabecular meshwork and cause high pressures at low volumes of blood; optic nerve ischaemia with moderate pressure rises.
• Risk factors for rebleeding: large initial hyphaema, poor initial vision, high pressure, anticoagulants and antiplatelets, sickle haemoglobinopathy, delayed presentation, and non-compliance.

• Pain, photophobia, blurred vision, and nausea and vomiting if pressure is high.
• Layered blood or clot in the anterior chamber (blood level on slit lamp or sitting up), reduced acuity, associated sphincter tear, iridodialysis, lens subluxation, vitreous haemorrhage, commotio retinae, choroidal rupture, and orbital fracture.
• Rebleed: sudden increase in blood and pain.
• Corneal blood staining: brown yellow central stromal discolouration.

• Visual acuity, slit lamp, intraocular pressure (when globe is closed), pupils, gonioscopy only after clearance (2 to 4 weeks), fundus view if possible.
• Exclude open globe with CT if suspected; B-scan ultrasound if no fundus view; orbital CT for fractures.
• Sickle cell screening (sickle solubility test or haemoglobin electrophoresis) in patients of African, Mediterranean, Middle Eastern and Indian ancestry; coagulation screen if bleeding disorder or anticoagulant use.
• Daily review of height of blood, pressure and cornea for the first 5 days.

• Outpatient management for minor hyphaema with reliable patient; admit when high risk (total hyphaema, high pressure, sickle cell, anticoagulation, non-compliance, children with possible non-accidental injury, and associated injuries).
• Rest with head elevated 30 to 45 degrees (to settle blood inferiorly), rigid shield, avoid strenuous activity, NSAIDs and aspirin; acetaminophen (paracetamol) for pain; avoid straining.
• Topical therapy:
  • Atropine 1 percent twice daily (or cyclopentolate 1 percent three times daily) for comfort and to decrease rebleeding risk.
  • Prednisolone acetate 1 percent four times daily (up to eight times daily with iritis), tapered over 1 to 2 weeks.
  • Pressure lowering for pressure above 25 mmHg: timolol 0.5 percent twice daily, brimonidine 0.2 percent three times daily (avoid in children under 12 years), dorzolamide 2 percent three times daily; oral acetazolamide 250 mg four times daily or IV mannitol 20 percent 1 to 2 g/kg for refractory pressure (avoid acetazolamide in sickle cell disease; avoid miotics and prostaglandin analogues).
• Antifibrinolytic therapy to reduce rebleeding: tranexamic acid 25 mg/kg orally three times daily (75 mg/kg/day; maximum 1.5 g per dose) for 5 days, or aminocaproic acid 50 mg/kg every 4 hours (maximum 30 g/day) for 5 days; avoid in thromboembolic risk and renal disease.
• Surgical washout (paracentesis, irrigation and aspiration, or automated vitrectomy cutter) indications:
  • Pressure above 50 mmHg for 4 days or above 35 mmHg for 7 days.
  • Total hyphaema with pressure above 25 mmHg for 5 days.
  • Early corneal blood staining.
  • Pressure above 25 mmHg for 24 hours in sickle cell disease or pressure above 35 mmHg for 24 hours in non-sickle patients with optic nerve compromise.
  • Hyphaema not clearing by 10 to 14 days (risk of peripheral anterior synechiae).
• Follow up: daily for 5 days, then at 1 and 4 weeks; gonioscopy at 4 weeks for angle recession; dilated examination for retinal injury; yearly pressure checks.
• Warn patients about rebleeding signs and activity limits for 2 to 4 weeks.