Blood In The Eye: Managing Hyphema

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Thursday our office got a phone call for an emergency work-in appointment.  A 13 year old boy got hit in the eye playing flag football at school, and now 2 hours later his vision was getting blurry.  A history like this definitely warranted him being seen as soon as possible, so thirty minutes later he was in my chair.  My technician gave me a quick over view before I went into the room, but I heard only one sentence before my mind immediately grasped out situation.  "And I can see blood in his eye!" A red eye is one thing, but when you see blood actually trapped inside the front of the eye, we're onto something much more serious.

I wish I had taken a picture of my patient, but the presentation was almost identical to this photo via
Hyphema is the medical term for a collection of blood cells in the anterior chamber of the eye (between the cornea and the iris).  Typically we see hyphema after blunt trauma to the eye, like being hit in the eye with a ball or an elbow.  The blood is typically due to a damage to the tiny blood vessels that run through the iris and the muscles around the iris (the ciliary body).  Because your eye is bleeding internally, it can't escape and is suspended within in the anterior chamber and begins to collect at the bottom of the cornea.  Vision is going to be cloudy because there are blood cells circulating inside the eye, but as a response to injury your body immediately mounts an inflammatory attack sending white blood cells to the area too.  Now you're looking through blood, and your body's own repair mechanism of proteins and inflammatory cells (called cells and flare).  Vision is going to be noticeably blurry as a result, and you well likely notice a significant increase in light sensitivity and a feeling of deep aching in and around the eye.  

As a result of inflammation and red blood cells being trapped in the eye, your intraocular pressure is going to shoot up.  My patient's IOP was 39 at presentation (and his other, uninjured eye was only 19).  The biggest risks for permanent vision loss due to hyphema is from untreated inflammation leaving IOP elevated for too long and causing glaucoma, or that the eye continues to rebleed, resulting in permanent clarity loss as red blood cells stain the cornea.  As many as 38% of people with hyphema will have a rebleed, which makes bed rest an essential part of your management plan.

We typically see hyphema in the office due to injuries during sports, but they can also occur spontaneously in patients using strong blood thinners or with hemolytic conditions.  The patient above had hyphema secondary to warfarin use. via

How To Treat
Depending on the amount of blood filling the anterior chamber and the age of the patient, you may be referred to a hospital setting to better monitor improvement around the clock and ensure absolute bed rest.  My patient only had about 10% of the anterior chamber filled with blood, which is quite commonly managed by your local optometrist or ophthalmologist in an out-patient setting.  The main goals of treatment are to reduce inflammation and stabilize the iris to reduce the risk of rebleeding.

1. Assess The Risk
The eye just suffered a blunt trauma, so you need to make sure there is no retinal break or detachment going on inside the eye.  With smaller hyphemas it's easy to get a view inside the eye after dilation; large amounts of blood in the anterior chamber may restrict the view too much.  This is where a referral for possible ultrasound may be necessary to make sure the patient doesn't need concurrent retinal detachment repair.

2. Stabilize The Iris
In office I went ahead and put in a drop of Atropine 1% to dilate the iris, giving me a great view of the retina to assess for a detachment, but just as importantly stabilizing the iris so it can't move around in response to different levels of light.  Prescribing a dilating agent until the blood has fully reabsorbed is a mainstay of hyphema treatment.  Atropine 2 x a day or Cyclopentolate 2-3 x a day are great options.  Homatropine used to be a favorite choice of doctors but it's not commercially available anymore.

In addition to paralyzing iris constriction and dilation with a cycloplegic drop, the patient needs to decrease their own movement as much as possible too.  Bed rest with the head elevated until the blood has fully reabsorbed is the general rule of thumb. At 13 years old, our patient was told to stay home from school (we supplied a note) and he was to stay in bed and rest as much as possible, getting up when necessary to only to eat, use the bathroom, and come to our office for follow-ups.  In cases of smaller hyphemas, the patient is typically monitored every 48 hours until the blood has reabsorbed to ensure improvement without rebleeds.

3. Reduce the Inflammation (and the IOP)
There is a ton of internal swelling going on, and a steroid eye drop is essential here.  Prednisolone acetate every 2 hours for the first day or two and then tapered in accordance to improvement is a good option. Remember to shake a lot  when using generic prednisolone.  Studies show that some generic versions of prednisolone need to be shaken as much as 50 times to get into proper suspension. For a time I tried to write branded Pred Forte only so my patients wouldn't have to deal with this crazy amount of shaking, but most pharmacies won't have branded prednisolone in stock, and your patient doesn't need to be waiting 24 hours to start treatment.  Go with generic for expediency, but shake and shake and shake.  

Because the blood in the eye is such a huge irritant (and a major trigger for inflammation!), starting the patient on prednisolone is usually all you need to bring down the IOP as well.  You can additionally add an IOP lowering agent like timolol (twice daily) or brimonidine (two to three times a day) if greater control is needed.  Prostaglandin analogue glaucoma drops aren't a good choice here because they increase ocular inflammation.  On prednisolone and cyclopentolate alone our patient's IOP dropped from 39 at presentation to 21 at the next visit.  We will continue to monitor IOP, presence and amount of red blood cells, and check for retinal breaks or tears every 48 hours until all blood has reabsorbed. Typically we'd expect resolution of hyphema in a healthy patient with only a small bleed to occur within 2 week's time. Avoiding another injury soon after hyphema is essential for minimizing risks of rebleed. Taking time away from contact sports for a few months is a good way to lower the chance of another injury so soon after the first.

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