What is Hyphema?
Hyphema is a condition where red blood cells gather in the front part of the eye known as the anterior chamber. This can be seen clearly either by direct observation or using a specific light testing device called a slit-lamp. This typically happens when the blood vessels in the iris (the colored part of the eye) or ciliary body (part of the eye that helps with focus) get damaged, often due to an injury or certain medical conditions.
The anterior chamber is the space in the eye surrounded by the cornea (the clear front surface of the eye), the angle (side part of the eye), and the lens and iris at the back. Usually, this area is filled with a clear fluid called aqueous humor, which is produced by the ciliary body and drains out through a small channel known as the Canal of Schlemm.
The angle of the eye is a very crucial area because it houses a mesh-like network and the Canal of Schlemm. It’s crucial because, if this area gets blocked, the drainage of the aqueous humor gets slowed down or stopped. This causes an increase in the pressure within the eye, a condition that can cause significant discomfort and vision problems.
What Causes Hyphema?
Hyphema, a condition where blood collects in the eye, is often caused by a blunt injury to the eye. However, it can also happen due to a puncturing eye injury or even spontaneously without a clear cause. Certain health issues can make a person more likely to experience hyphema. These include blood diseases like leukemia, hemophilia, von Willebrand disease, and sickle cell disease, as well as the use of blood-thinning medications.
People with new blood vessel growth in their eyes, often seen in people with diabetes, are also more at risk. Additionally, some patients may develop hyphema during surgery or up to a week after surgery.
Risk Factors and Frequency for Hyphema
Traumatic hyphema, a type of eye injury, affects 12 out of 100,000 people, with most of these cases (70%) happening in children. This condition is most frequently observed in boys aged 10 to 20 years old, who often sustain the injury while playing sports or doing other recreational activities. For children, injuries from ball sports like baseball, basketball, softball, or soccer are common. Here, the injury usually happens when the ball hits the front part of the eye. On the other hand, teenagers and adults are more likely to get such injuries from a hard smack to the eye, often during a physical assault. Some other causes include paintball guns, airsoft guns, and airbag deployments in cars.
Signs and Symptoms of Hyphema
Generally, people with hyphema have a history of eye injury or recent eye surgery. When such patients turn up, medical professionals need to conduct a detailed examination and seek information about the incident. This could involve questions about objects entering the eye, changes in vision, light sensitivity, eye pain, nausea, vomiting, and any history of bleeding disorders, including sickle cell disease.
It’s very important to check for potential severe eye injuries, like open globes or penetrating wounds. If a penetrating injury is detected, it’s safe to assume there’s an open globe injury as well. In such cases, any objects that have entered the eye should be left where they are, the eye should be covered with a protective shield, and the patient should immediately consult an eye specialist in the emergency department. If the injury was caused by trauma, the patient should also be checked for acute orbital compartment syndrome, a condition that causes bulging of the eye, reduced vision, and certain eye reflex abnormalities.
Once severe injuries are ruled out, a comprehensive evaluation of the eye can be done. This includes inspection of the eyelids, eyelashes, tear system, and the cornea. Checks should be done for direct and consensual pupillary responses, visual acuity, confrontational visual fields, and the movement of extra-ocular muscles. Typical findings in hyphema include decreased visual acuity, sensitivity to light, unequal pupil size, and visible blood in the front portion of the eye.
In cases of hyphema, vision tends to worsen when lying flat and may improve with the head elevated, due to the blood settling below the line of sight. Reduced vision happens because the blood in the front part of the eye distorts the light path, causing inaccurate focusing on the retina. Unequal pupil size stems from damage to the iris sphincter muscles, which could cause either constriction or dilation of the affected eye.
Hyphema is rated based on the volume of blood in the front part of the eye. Grade 0 or microhyphema has scattered blood cells in the anterior chamber that do not layer out. In grade I, less than a third of the anterior chamber is filled with blood. Grade II has one third to half filling. Grade III has more than half but not total filling. Lastly, grade IV has complete filling of the anterior chamber.
Testing for Hyphema
If you have been injured and there’s a chance of other physical damages, doctors might perform a comprehensive trauma assessment. As part of this, a special microscope called a slit lamp may be used for a closer look at your eye if it’s suspected that you have hyphema, a condition where blood pools in the front part of your eye.
The doctor will use a dye called fluorescein to check for any scratches on your cornea, the transparent front layer of the eye. This is done before measuring the pressure inside your eye because using fluorescein after the measurement can give false positive results. Once it’s confirmed that you don’t have an open globe injury, which is a full-thickness injury of the eyeball wall, the doctor will measure your eye pressure. Elevated eye pressure is considered if the measurement is above 21 mm Hg.
If you’re on blood thinners, or have a high chance of bleeding due to a certain condition, a complete blood count (CBC) and a clotting test may be performed. Also, if you have a family history of sickle cell disease, or if it’s not sure, you may be tested for this condition as it affects the red blood cells and can complicate the condition.
A computerized tomography (CT) scan, which provides detailed images of the inside of your body, may be done to check for further injuries in your eyes. This includes confirming if there’s a break in the outer layer of your eye (open globe injury), a foreign body inside your eye, or a suspected break in the bone that surrounds your eye (orbital fracture). Ultrasound, which uses sound waves to produce images, may be useful to evaluate lens dislocation, foreign body inside the eye, detachment of the retina (light-sensitive tissue at the back of your eye), and blood leakage in the back of your eye (posterior vitreous hemorrhage). However, the ultrasound should only be performed once it’s confirmed that you don’t have an open globe injury, as pressing the eye with the ultrasound probe could potentially worsen the injury.
Treatment Options for Hyphema
Treating hyphema, a condition where blood collects in the front part of the eye, starts by identifying any immediate threats to the eyesight or life-threatening situations. Since hyphema often results from an injury, patients may need other treatments too. In this situation, certain medications that could raise the pressure inside the eye are avoided. Instead, alternative medications that don’t increase this pressure are used.
If the patient has high pressure in the eye, they need to see an eye doctor straight away and might need a procedure to reduce the pressure. Even though it can be difficult to decide when the pressure is back to normal due to hyphema’s effects, it’s important to perform this procedure promptly and have them assessed in the emergency department by an eye specialist.
If a patient has an open eye injury with a foreign object like a projectile in the eye, they need to avoid moving, coughing, or sneezing a lot to prevent further harm. Medicine to relieve pain and prevent vomiting are given. A protective shield is placed around the object. Foods and drinks are avoided, and an eye surgeon is called for an urgent operation to fix the injury and remove the object. Antiboitoics are given to avoid any infection, and their tetanus status is checked and updated if necessary.
To treat hyphema, the head of the bed is raised at least 30 degrees. This helps the red blood cells settle at the bottom of the eye and out of sight. Pain is controlled using drops or painkillers, and nausea is managed using various medications. Once it’s established that the patient doesn’t have a specific eye condition called acute glaucoma, certain eye drops can be used to control the pain. However, these should only be prescribed by an eye doctor who can also keep monitoring the eye pressure. Patients should also avoid tasks that can increase the risk of further bleeding, like reading.
Some eye doctors suggest using steroid eye drops. However, while these can decrease the risk of further bleeding, they may slow healing if there are associated scratches on the cornea.
Patients with conditions that affect blood clotting should have these managed appropriately. Those who satisfy certain criteria may go home but will be checked daily by an eye specialist. Those who do not fit these criteria will remain in the hospital for further management. Meanwhile, patients should avoid substances like pain relievers that can interfere with normal blood clotting.
In certain cases, surgery to remove the blood from the eye is required, especially when complications like staining of the cornea with blood or damage to the optic nerve from high eye pressure happen. The specific situations when surgery is needed can be identified based on certain measurements of eye pressure and how the hyphema changes with time. Patients with sickle cell disease, a genetic disorder affecting red blood cells, are at a higher risk of severe increases in eye pressure and may also require surgery under specific circumstances.
What else can Hyphema be?
Doctors consider the following conditions when diagnosing hyphema:
- Complications and management of glaucoma filtering
- Herpes simplex virus keratitis
- Juvenile xanthogranuloma
- Ophthalmologic manifestations of sickle cell disease
- Uveitic glaucoma
What to expect with Hyphema
Most patients fully recover without any long-term problems. However, complications are more likely in those with existing health conditions such as sickle cell disease or an increasing size of hyphema (a pooling of blood inside the front part of the eye).
Intraocular pressure (pressure inside the eye) can rise after a hyphema. It’s seen in roughly 13.5% of less serious (grade I to II) hyphemas. More severe (grade IV) hyphemas, have a 52% chance of elevated intraocular pressure.
The likelihood of retaining normal vision after a hyphema also depends on the severity of the hyphema. For less severe hyphemas (grade I), about 90% of people have normal vision afterward. However, for the most severe cases (grade IV), only 50% to 75% of patients maintain normal vision.
The most common cause of impaired vision after hyphema is staining of the visual axis (the clear path that light travels through the eye). This problem is more common in severe hyphemas, illustrating the lower chance of a good outcome with higher-grade injuries.
Possible Complications When Diagnosed with Hyphema
: The two main urgent complications of hyphemas, which are pools of blood in the eye, are high pressure in the eye and re-bleeding. Acute high eye pressure is often encountered in emergency room settings. This high pressure occurs when blood blocks the eye’s drainage system, preventing efficient drainage of eye fluids.
A specific condition that requires attention is Sickle Cell Disease. The removal of a hyphema requires red blood cells (RBCs) to pass through the eye’s drainage system. However, the front part of the eye has low levels of oxygen which can cause RBCs to change shape in those at risk. As this shape change gets worse, the RBCs get stuck in the drainage canal, leading to a rise in eye pressure.
Patients with eye pressure greater than 21 mm Hg should be treated similarly to cases of non-traumatic acute glaucoma. An eye specialist should be consulted as there isn’t a specific method of treatment. Several medications are available to reduce the flow of eye fluids. These include eye drops like timolol, and medications like apraclonidine and brimonidine. Medications to reduce carbonic acid, such as dorzolamide or systemic acetazolamide, can also be used. However, caution should be taken as these medications can worsen the shape change of RBCs in patients with Sickle Cell Disease. It’s recommended to discuss treatment options with an eye specialist, as many different combinations of medications exist. About 5% of patients will still have high eye pressure requiring surgery to remove the blood clot.
After the first bleed, re-bleeding can happen 2 to 5 days later. This increases the risk of permanent vision loss and is seen in about 30% of cases. In patients at higher risk, the use of a medicine to slow down or stop blood clot breakdown is no longer encouraged as studies did not show decreased rates of re-bleeding.
A rare complication called corneal blood staining can occur in patients with a total hyphema, which means that the whole front part of the eye is filled with blood. Out of 289 patients, 2.1% developed corneal blood staining. The recommended way to prevent this is called an anterior chamber washout.
Common Complications:
- High eye pressure
- Re-bleeding
- Corneal blood staining
