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Hyphema

Overview
Postinjuryaccumulationofbloodintheanteriorchamberisoneofthemostchallengingclinicalproblems
encounteredbytheophthalmologist.Evenasmallhyphemacanbeasignofmajorintraoculartraumawith
associateddamagetovascularandotherintraoculartissues.

Hyphema
Blunttraumatotheeyemayresultininjurytotheiris,papillarysphincter,anglestructures,lens,zonules,retina,
vitreous,opticnerve,andotherintraocularstructures.Blunttraumaassociatedwitharapid,markedelevationin
intraocularpressurewithsuddendistortionofintraocularstructuresproducesthedynamicchangesresponsiblefor
Author:JohnDSheppardJr,MD,MMScChiefEditor:HamptonRoySr,MD
hyphemaformation.
more...
Thelackofanidealtherapeuticprogram,thepotentialforsecondaryhemorrhage,andthesecondaryonsetof
Updated:Dec6,2013
glaucomaallthreatentoturnaneyewithaninitiallygoodvisualprognosisintoacomplextherapeuticproblemwith
apoorfinalvisualresult.

Classificationandcharacteristics
Traumatichyphemaisencounteredinchildrenandadults.Hyphemaisusuallytheresultofaprojectileordeliberate
punchthathitstheexposedportionoftheeyedespitetheprotectionofthebonyorbitalrim.Variousmissilesand
objectshavebeenincriminated,includingballs,rocks,projectiletoys,airgunpellets,BBgunpellets,hockeypucks,
bungeecords,paintballs,andthehumanfist. [1,2,3]Morerecently,airgunpelletsandBBgunpelletshavebeen
madeofplasticpolymers.Therehaveevenbeencasesinvolvingobjectslargerthantheorbit,suchassoccerballs.
[4]Slowmotionphotographyhasdemonstrateddeformationofthesoccerballsasimpactoccurswiththeorbitalrim,
therebycausingthehyphema.Withtheincreaseofchildabuse,fistsandbeltshavestartedtoplayaprominent
role.Malesareinvolvedinthreefourthsofcases. [5,6]
Hyphemacanalsooccurintraoperativelyorpostoperatively.Surgicalhyphemaisaknowncomplicationofintraocular
surgeryandshouldbemanagedinasimilarmannerastraumatichyphema.
Rarely,spontaneoushyphemasmayoccurandbeconfusedwithtraumatichyphemas.Spontaneoushyphemasare
secondarytoneovascularization(eg,diabetesmellitus,ischemia,cicatrixformation),ocularneoplasms(eg,
retinoblastoma),uveitis,andvascularanomalies(eg,juvenilexanthogranuloma).Vasculartuftsthatexistatthe
pupillaryborderhavebeenimplicatedinspontaneoushyphemas. [7]
TheangularvesselsfirstdescribedbyArlt,asseeninFuchsuveitissyndrome,produceafiliformangular
hemorrhageandsubsequentmicrohyphemawhenadiagnostic30gaugeneedleisplacedthroughthelimbus.This
isknownasArltssign.
Finally,anidiopathichyphemamayoccurwithspontaneousresolutionandnoknowncauseorrecurrence.Thisis
extremelyrare.
Thefollowingclinicalgradingsystemfortraumatichyphemasispreferred:
Grade1Layeredbloodoccupyinglessthanonethirdoftheanteriorchamber
Grade2Bloodfillingonethirdtoonehalfoftheanteriorchamber
Grade3Layeredbloodfillingonehalftolessthantotaloftheanteriorchamber
Grade4Totalclottedblood,oftenreferredtoasblackballor8ballhyphema
Mosthyphemasfilllessthanonethirdoftheanteriorchamber.Whenhyphemasaredividedinto4groupsaccording
totheamountoffillingoftheanteriorchamber,58%involvelessthanonethirdoftheanteriorchamber,20%
involveonethirdtoonehalfoftheanteriorchamber,14%involveonehalftolessthantotaloftheanterior
chamber,and8%aretotalhyphemas.Slightlyfewerthanonehalfofallhyphemassettleinferiorlytoformalevel
approximately40%formadefiniteclot,usuallyadherenttotheirisstromaand10%haveadarkclotincontactwith
theendothelium.Thislastformmayportendapooroutcomeandcornealstaining.
Analternativemethodofgradinghyphemasinvolvesmeasuring(inmillimeters)thehyphemafromtheinferior6
o'clocklimbus.Thismethodmayhelpinmonitoringtheprogressofresolutionortheoccurrenceofrebleeding.
Digitalimaginganalysisisalsousefulandobjectivebutisavailableinonlyafewresearchoracademicfacilities.
Thecauseofananteriorchamberhemorrhageincontusioninjuriesisthoughttoberelatedtotheposterior
displacementoftissueortotheresultantfluidwaveintheaqueoushumorandthevitreous.Thissuddendynamic
shiftstretchesthelimbalvesselsanddisplacestheirisandthelens.Thisdisplacementmayresultinatearatthe
irisortheciliarybody,usuallyattheanglestructures. [8]Atearattheanterioraspectoftheciliarybodyisthemost
commonsiteofbleedingandoccursinabout71%ofcases. [9]Thebloodexitsfromtheanteriorchamberviathe
trabecularmeshworkandtheSchlemmcanalorthejuxtacanaliculartissue.
Theusualdurationofanuncomplicatedhyphemais56days.Themeandurationofelevatedintraocularpressureis
6days.

Pathophysiology
Hyphemadescribestheconditionoftheaqueoushumorwhenredbloodcellsformasuspensioninit.
Thechoroidandtheiriscontainarichcomplexofvessels.Thepupilisoutlinedandcontrolledbyacomplexsetof
iridialmuscles,sphincters,anddilators.Thesemusclescanberupturedbysharpand/orblunttrauma.Thisisa
frequentsourceofintraocularhemorrhage(hyphema).Inaddition,theirisrootand/ortheciliaryspurisacommon
locationofbleedingfromblunttrauma.
Surgicalinterventionintotheeyeforanteriorsegmentproceduresisaccomplishedroutinelythroughvarious
approaches.Themostcommonlyusedapproachesinmodernsmallincisionsurgeryareviathelimbusand/orthe
clearcornea.Clearcorneasurgerymarkedlyreducestheriskofbleedingfromlimbalvesselssincethecorneainits
healthystateisavascular.Scleraltunnelincisionissubjecttounpredictablehemorrhage,andtheincisionmustbe
closedcarefullywithsutures.
Hyphemacanoccurasaresultofintraocularsurgery,asfollows:
IntraoperativebleedingCiliarybodyoririsinjuryseenduringaperipheraliridectomy,cataractextraction,
cyclodialysis,andfiltrationprocedure(laserperipheraliridectomy,especiallywithYAGlaserthanwithargon
laserargonlasertrabeculoplasty[ALT]notverycommon)
Earlypostoperativebleeding(atraumatizeduvealvesselthatwasinspasmandsuddenlydilates
conjunctivalbleedingthatmakesitswayintotheanteriorchamberviaacorneoscleralwoundorsclerostomy)

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Latepostoperativebleeding(newvesselsgrowingacrossthecorneoscleralwoundthatbleedwhen
manipulatedauvealwoundthatisreopenedanintraocularlens[IOL]thatcauseschroniciriserosion)

Frequency
IntheUnitedStates,theincidenceofhyphemais1720per100,000peopleperyear.

Differentials
HerpesSimplex
HerpesZoster
JuvenileXanthogranuloma
Keratoconjunctivitis,Atopic
Melanoma,Choroidal
Melanoma,CiliaryBody
Melanoma,Iris
Retinoblastoma
Uveitis,FuchsHeterochromic

Otherproblemstobeconsidered
Trauma
Intraocularsurgery
Spontaneoushyphema
Irismicrohemangiomas,irisvarix,andpupillarymicrohemangiomas
Irisneovascularization
Clottingdisorders
Followinglasertrabeculoplasty[10]oriridotomy
Anticoagulationtherapy,suchaswarfarin(Coumadin),clopidogrelbisulfate(Plavix),oraspirin

ElevatedIntraocularPressure
Increasedintraocularpressuresmayaccompanyhyphemasofanysize.Elevatedintraocularpressures(>22mmHg)
maybeanticipatedinapproximately32%ofallpatientswithhyphemasatsometimeduringtheircourse. [9]Higher,
moreprolongedelevationsofintraocularpressurearemorecommonlyassociatedwithneartotalortotalhyphemas.
Patientspredisposedtoglaucomaorwithpreexistingglaucomaanddecreasedfacilityoftrabecularoutflowarealso
morelikelytodevelopglaucomawithahyphema.
Thesehighlyelevatedintraocularpressuresoccurduringtheacutephaseofthehyphemaandareseparatefrom
thoserelatedtoanglerecession. [11]Inpatientswithpressureelevations,abnormaltonometricreadingsare
frequentlydetectedduringthefirst24hoursafterinjury.Thisinitialperiodofelevatedintraocularpressureisoften
followedbyaperiodofnormalorbelownormalpressurefromtheseconddaytothesixthday.Carefulmonitoringof
theintraocularpressureisimportantandmaydeterminethecourseoftreatment. [12]Theearlyperiodofelevated
intraocularpressureisprobablytheresultoftrabecularpluggingbyerythrocytesandfibrin.Thefollowingperiodof
reducedpressureismostlikelyduetoreducedaqueousproductionanduveitis,anditmayactuallyincreasethe
chanceofsecondaryhemorrhage.Thisperiodofhypotonyiscommonlyfollowedbyasubsequentriseinintraocular
pressure,probablycoincidentalwiththerecoveryoftheciliarybody.
Intraocularhypertensionthensubsideswithrecoveryofthetrabecularmeshworkanddisappearanceofthe
hyphema.
Exceptionsincludepatientswithahyphemaoccupyinggreaterthan75%oftheanteriorchamberandthosewitha
totalhyphema,inwhompressureelevationfrequentlyhasitsonsetsimultaneouslywiththeinitialhyphemaand
remainscontinuallyelevateduntilthehyphemahashadconsiderableresolution.Whenlargesegmentsofthe
anteriorchamberangleareirreparablydamagedand/orwhenorganizationofthefibrinorclotproducesextensive
peripheralanteriorsynechiae,theintraocularhypertensioncontinues,becomingintractableglaucoma.
Ghostcellglaucomawithhyphemaandvitreoushemorrhagemaycauseelevatedintraocularpressure2weeksto3
monthsaftertheinitialinjury. [13]Gradualclearingofthehyphemaoccurs,witherythrocyteslosinghemoglobinand
becomingsocalledghostcellsinthevitreouscavity.Theghostcellsthencirculateforwardintotheanterior
chamber,withresultanttrabecularblockageduetothedistorted,bulkyconfigurationofthecrenatedredbloodcell.
Considerabledelayedelevationofintraocularpressuremayoccurwithghostcellglaucoma,particularlyinpatients
withpoorfacilityofoutflow.

SecondaryHemorrhage
Secondarybleedingintotheanteriorchamberresultsinamarkedlyworseprognosis.Eventualvisualrecoverytoa
visualacuityof20/50(6/15)orbetteroccursinapproximately64%ofpatientswithsecondaryhemorrhageas
comparedwith79.5%ofpatientsinwhomnorebleedingoccurred. [5,9]Truesecondarybleedingintotheanterior
chamberisindicatedbyanobviousincreaseintheamountofbloodintheanteriorchamber.Secondaryhemorrhage
occursinapproximately25%(range,738%)ofallpatientswithhyphema. [5,9]Theincidenceofsecondary
hemorrhageishigherinhyphemasclassifiedasGrades3and4. [6]
Withneartotaltototalhyphemas,inwhichthebloodisdarkandclotted,brightredbloodoftenbeginstoappearat
theperipheryoftheclotonthefourthdaytothesixthday.Thisprobablyresultsfromearlydissolutionoftheclot
anddoesnotnecessarilyindicateasecondaryhemorrhage.Alargeproportion(33%)ofpatientsyoungerthan6
yearshassecondaryhemorrhagesthelikelihoodofsecondaryhemorrhagesdecreaseswithage.Secondary
hemorrhageusuallyoccursonthethirddayorthefourthday,butitmayoccurfromtheseconddaytotheseventh
dayaftertrauma. [5,14]
Secondaryhemorrhageisprobablyduetolysisandretractionoftheclotandfibrinaggregatesthathaveoccluded

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theinitiallytraumatizedvessel. [9]Thesecondarybleedingmayresultinincreasedintraocularpressureandcorneal
stainingandisassociatedwithapoorervisualprognosis. [15,16]
SeveralstudieshavedocumentedthatsecondaryhemorrhageoccursmorefrequentlyinAfricanAmericanpatients.
In1990,Spooretalobservedsecondaryhemorrhagein24.2%ofAfricanAmericanpatientsandinonly4.5%of
whitepatients. [17]TwootherstudiesdemonstratedgreaterratesofsecondaryhemorrhageinAfricanAmerican
patientsthatarehighlysignificant(P<0.05). [18,19]Intheinitialsystemicaminocaproicacid(ACA)study,African
Americanpatientscomprised66.2%ofthepopulation[9]34%ofAfricanAmericanpatientsintheplacebogroup
developedsecondaryhemorrhage,and20%ofthemhadpositivesicklecelltraitbyhemoglobinelectrophoresis.
Therehavealsobeenstudiesshowingahigherincidenceofrebleedingincasesofhemophilia. [20]

PostoperativeHyphema
Earlypostsurgicalhyphemascanbecausedbybleedingfromtheciliarybody,fromcutendsoftheSchlemmcanal,
fromtheirisoririsroot,andfromthecorneoscleralwounds.Woundslocatedmoreposteriorlytendtobleedmore.
Irisneovascularizationcanalsoresultinahyphemaduetofragileirisvesselsthatcanbleedfromintraoperative
manipulation.
Lateonsetpostsurgicalhyphemasoccurfromthefinearborizingneovascularvesselsthatformintheinneraspectof
thecataractincisionsite.Thesevesselsarefragileandbleedspontaneouslyafterminortrauma.Hyphemasinthis
settingmaybecausedbyposteriorchamberintraocularlens(PCIOL)hapticserodingtheciliarysulcus.Anterior
chamberintraocularlens(ACIOL)hapticsalsomaycausebleedingbychafingtheirissurface.
Rubeosis,oririsneovascularization,canalsobeasourceoflatepostoperativehyphema.
Uveitisglaucomahyphema(UGH)syndromeisseenweekstomonthsaftersurgery.Postoperativehyphemamay
alsooccurafterlaserprocedures.
AfterALT,bleedingmayoccurfromaninadvertentlasertreatmentoftheirisrootvesselorfromrefluxofbloodin
theSchlemmcanal.
Afteralaseriridotomy,bleedingmayoccurfromaninadvertentlasertreatmentoftheirisrootvessel.Thephysician
shouldapplypressurewiththefocusinglenstoreducetherateofbleedingandthesizeofhyphemaformationif
promptlyrecognized.

ComplicationsofHyphema
Complicationsoftraumatichyphemamaybedirectlyattributedtotheretentionofbloodintheanteriorchamber.
Thefourmostsignificantcomplicationsincludeposteriorsynechiae,peripheralanteriorsynechiae,corneal
bloodstaining,andopticatrophy. [9,21]

Posteriorsynechiae
Posteriorsynechiaemayforminpatientswithtraumatichyphema.Thiscomplicationissecondarytoiritisor
iridocyclitis.However,theyarerelativelyrarecomplicationsinpatientswhoaremedicallytreated.Posterior
synechiaeoccurmorefrequentlyinpatientswhohavehadsurgicalevacuationofthehyphema.

Peripheralanteriorsynechiae
Peripheralanteriorsynechiaeoccurfrequentlyinmedicallytreatedpatientsinwhomthehyphemahasremainedin
theanteriorchamberforaprolongedperiod,typically9ormoredays.Thepathogenesisofperipheralanterior
synechiaemaybeduetoaprolongediritisassociatedwiththeinitialtraumaand/orchemicaliritisresultingfrom
bloodintheanteriorchamber.Alternately,theclotinthechamberanglemaysubsequentlyorganize,producing
trabecularmeshworkfibrosisthatclosestheangle.Bothmechanismsarelikelytobeinvolved. [5,9]

Cornealbloodstaining
Cornealbloodstainingprimarilyoccursinpatientswithatotalhyphemaandassociatedelevationofintraocular
pressure.Thefollowingfactorsmayincreasethelikelihoodofcornealbloodstainingallofthesefactorsaffect
endothelialintegrity:
Initialstateofthecornealendotheliumdecreasedviabilityresultingfromtraumaoradvancedage(eg,
corneaguttata)
Surgicaltraumatotheendothelium
Largeamountofformedclotincontactwiththeendothelium
Prolongedelevationofintraocularpressure
Cornealbloodstainingmayoccurwithlowornormalintraocularpressurerarely,itmayalsooccurinlessthantotal
hyphemas.However,theselatter2instancesprobablycanbeanticipatedonlyineyeswithaseverelydamagedor
compromisedendothelium.Cornealbloodstainingismorelikelytooccurinpatientswhohaveatotalhyphemathat
remainsforatleast6dayswithconcomitant,continuousintraocularpressuresofgreaterthan25mmHg. [5]Clearing
ofthecornealbloodstainsmayrequireseveralormanymonths.Generally,thecornealbloodstainsformcentrally
andthenspreadtotheperipheryofthecornealendothelium.Duringresolution,cornealbloodstainingclears
peripherallyandthencentrally,reversingthesequenceoftheinitialstainingprocess.

Opticatrophy
Opticatrophymayresultfromeitheracute,transientlyelevatedintraocularpressureorchronicallyelevated
intraocularpressureeachoccurrencewasstudiedinaseriesofpatientswithhyphemainanattempttoidentify
predisposingfactors. [9,22]
Nonglaucomatousopticatrophyinpatientswithhyphemamaybeduetoeithertheinitialtraumaorthetransient
periodsofmarkedlyelevatedintraocularpressure.Diffuseopticpallor(andnotglaucomatouscupping)istheresult
oftransientperiodsofmarkedlyelevatedintraocularpressure.Palloroccurswithconstantpressureof50mmHgor
higherfor5daysor35mmHgorhigherfor7days. [5,9]
Theauthorshaveobservednumerouspatientswithsicklecelltraitwhodevelopedanonglaucomatousopticatrophy
withrelativelylowelevationsofintraocularpressureof3539mmHgfor24days. [5]Inspiteofmaximummedical
therapy,finalvisualacuitywaslessthan20/400inallpatients.Theauthorscontinuetoobserveopticatrophyin
patientswithsicklecelltraitwhoarereferredtotheirinstitutionandwhohavenothadvigorouscontrolofintraocular
pressureand/ordelayinparacentesis.Otherstudiesindicatethatpatientswithsicklecellhemoglobinopathiesand
anteriorchamberhyphemashavemoresicklederythrocytesintheiranteriorchambersthanintheircirculating

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venousblood. [23]Thesicklederythrocytesobstructthetrabecularmeshworkmoreeffectivelythanhealthycells,and
aconsequentelevationofintraocularpressureoccurswithlesseramountsofhyphema.
Systemichypotensiveagents,suchasacetazolamideandmethazolamide,maynotalwaysbesuccessfulinreducing
theintraocularpressure.Infact,theymaybecontraindicatedinhighorrepeateddoseregimensbecauseoftheir
possiblecontributiontointravascularhemoconcentrationandincreasedmicrovascularsludging,bothofwhichare
detrimentalinsicklecellhemoglobinopathy.
Theincreasedintraocularpressuremaynotbetoleratedwellinthesepatientsbecauseoftheincreased
susceptibilitytoimpairedvascularperfusionwithintheopticnerveandtheretina.Indeed,moderateelevationof
intraocularpressureinpatientswithsicklecellhemoglobinopathymayproducerapiddeteriorationofvisualfunction
becauseofprofoundreductionofcentralretinalarteryandposteriorciliaryarteryperfusion. [24,25]ForAfrican
Americanpatients,thepreventionofsecondaryhemorrhageisacriticalfactor.
Othercomplicationsassociatedwithhyphemainvolvedisruptionoftheposteriorsegment.Thesecomplications
include,butarenotlimitedto,choroidalrupture,macularscarring,retinaldetachment,vitreoushemorrhage,and
zonulardialysis.Evenacaseofsympatheticophthalmiafollowinghyphemahasbeenreported. [26]

PrognosisandTreatment
Recognizingthattheprognosisforvisualrecoveryisdirectlyrelatedtothefollowing3factorsisimportant:
Amountofassociateddamagetootherocularstructures(ie,choroidalrupture,macularscarring)
Whethersecondaryhemorrhageoccurs
Whethercomplicationsofglaucoma,cornealbloodstaining,oropticatrophyoccur
Treatmentmodalitiesshouldbedirectedatreducingboththeincidenceofsecondaryhemorrhageandtheriskof
cornealbloodstainingandopticatrophy.
Thesuccessofhyphematreatment,asjudgedbytherecoveryofvisualacuity,isgoodinapproximately75%of
patients.Approximately80%ofthosewithlessthanonethirdfillingoftheanteriorchamberregainvisualacuityof
20/40(6/12)orbetter.Approximately60%ofthosewithahyphemaoccupyinggreaterthanonehalfbutlessthan
totaloftheanteriorchamberregainvisualacuityof20/40(6/12)orbetter,whileonlyapproximately35%ofthose
withaninitiallytotalhyphemaoraGrade4hyphemahavegoodvisualresults.Approximately60%ofpatients
youngerthan6yearshavegoodvisualresultsolderagegroupshaveprogressivelyhigherpercentagesofgood
visualrecovery.
Theseverityofthetraumaisfrequentlyrelatedtothefinalvisualoutcome.Lensopacities,choroidalrupture,
vitreoushemorrhage,anglerecessionglaucoma,secondarymacularedema,andretinaldetachmentarecommonly
associatedwithtraumatichyphema,compromisingthefinalvisualresult.
Ofpatientswithhyphema,14%havepoorvisualresultsfromassociatedtrauma,includingsuchcomplicationsas
glaucoma,vitreoushemorrhage,retinaldetachment,choroidalrupture,orscleralrupture.Poorvisualoutcomein
traumatichyphemacanbedirectlyattributedtothehyphemain11%ofpatients[22,9]thepoorvisualoutcomeis
usuallytheresultofsecondaryhemorrhageassociatedwithopticatrophyorcornealbloodstaining.
Forexcellentpatienteducationresources,visiteMedicineHealth'sEyeandVisionCenter.Also,see
eMedicineHealth'spatienteducationarticlesHyphema(BleedinginEye)andEyeInjuries.

Workup
Labstudies
InAfricanAmericanpatients,asicklecellprepshouldbeorderedifahyphemaisseenbecausethepresenceofa
hyphemainpatientswithsicklecelltraitordiseasecanproducesignificantocularcomplications.Sickledredblood
cellscanmoreeasilyobstructthetrabecularmeshworkandresultinahighIOP,eveninthepresenceofarelatively
smallhyphema.Inaddition,ischemiccomplicationsoftheretinaandtheopticnervearegreaterinpatientswith
sicklecelltraitanddisease.
Ahemoglobinelectrophoresisisalsohelpful.Ithelpsdistinguishsicklecelltraitfromdiseaseoncethesicklecell
prepispositive.

Imagingstudies
Infrequently,aBscanand/oraCTscanmaybenecessarytoruleoutanintraoculartumororaforeignbodyifa
thoroughexaminationisnotpossibleandthereasonsforpostoperativehyphemaarenotclear.

Othertests
Rarely,anirisfluoresceinangiogrammaybeneededifearlyirisneovascularizationissuspectedasanunderlying
causeofthehyphema.

Gonioscopy
Examinationoftheanglestructuresiscriticaltounderstandingtheextentoftheblunttraumaprecipitatinga
hyphema.Thiscanbedelayeduntilafterthecritical5day,highrisk,rebleedperiod,particularlydynamic
gonioscopy.Angleabnormalities,synechiae,andrecessionmaycommonlybefound.Rarely,afocusofbleeding
canbephotocoagulatedwiththeargonlaseronlowpowersettings,upto300mWwitha200mspotsize.

MedicalManagement
Thecustomarytreatmentofpatientswithtraumatichyphemahasincludedhospitalization,bedrest,bilateral
patching,topicalcycloplegics,topicalsteroids,systemicsteroids,andsedation. [27]However,studieshavenot
indicatedthatrigidlyfollowingthisregimenisnecessarytoachieveacceptabletherapeuticresults.Thesestudies
provideevidencethatnostatisticallysignificantdifferenceexistsinmostareasofcomparisonbetweenpatients
treatedwithbedrest,bilateralpatches,andsedationandthosetreatedwithambulation,apatchandshieldonthe
injuredeyeonly,andnosedation. [9,28,29,30]Theauthorsrecommendambulationandapatchandshieldforthe
injuredeye.Sedationisrecommendedonlyintheextremelyapprehensiveindividual.Hospitalizationmaybe
warrantedincasesofseveretraumaandrebleeding.
Ifanalgesicsarerequiredforpainrelief,acetaminophen(Tylenol)withorwithoutcodeine,dependingontheseverity
ofthepain,ispreferred.Theantiplateleteffectofaspirintendstoincreasetheincidenceofrebleedinginpatients
withtraumatichyphemaandshouldbestrictlyavoided. [15]Nonsteroidalantiinflammatorydrugs(NSAIDs)with
analgesicactivity,suchasmefenamicacid(Ponstel)ornaproxen(Aleve),sharethisdeleteriousantiplateleteffect.

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Inanytherapeuticregimen,theinjuredgloberequiresadequateprotectionwithapatchandshield. [31]Elevatingthe
headofthebed3045facilitatessettlingofthehyphemaintheinferioranteriorchamberandaidsinclassifyingthe
hyphema.Inferiorsettlingfacilitatesmorerapidimprovementofvisualacuity,earlierevaluationoftheposterior
pole,andgreaterclearingoftheanteriorchamberangle.Abetterestimateofthedecreaseorincreaseinthe
amountofbloodintheanteriorchamberisalsopossibleduringsubsequentbiomicroscopeexaminations.
Varioustopicalmedicationshavebeenrecommendedfortreatingpatientswithtraumatichyphema,including
cycloplegicsfortraumaticiridocyclitisandmioticstoincreasethesurfaceareaoftheiristoenhanceresorptionofthe
hyphema. [16,32,33]Topicalcorticosteroidsandestrogens[33,34]havebeenrecommendedwithcontradictoryresults.
[34]

Investigationsconductedbytheauthorsofpatientswithtraumatichyphemaexcludedtheuseoftopicalmedications
becauseofalackofdefiniteevidenceoftheiradvantages. [5,22]Onerecommendationregardingtopicalmedication
isthatthetopicaluseofsteroidsafterthethirddayorthefourthdayofretainedhyphemamaybeadvantageousto
decreasetheassociatediridocyclitisandtopreventordeterthedevelopmentofperipheralanteriorsynechiaeor
posteriorsynechiae.Secondly,topicalatropine(1%)isindicatedinhyphemasoccupyingmorethan50%ofthe
anteriorchambertobreakthepupillaryblock.
Severaldoublemaskedstudiesclearlyestablishthevalueofsystemicaminocaproicacid(ACA,AMICAR)inthe
preventionofrecurrenthemorrhages. [5,35]Ifsecondaryhemorrhagesaretheresultoflysisandretractionofaclot
thathasproducedanocclusionofthetraumatizedvessel,thenpreventionofnormallyoccurringclotlysisfor56
daysshouldbeadvantageoustoallowtheinjuredbloodvesseltomorecompletelyrepairitsintegrity. [5]The
antifibrinolyticactivityofACAgivensystemicallyhasbeendemonstratedinotherareasofthebodytodecreasethe
incidenceofsecondaryhemorrhage.
ACAretardsclotlysisbypreventingplasminfrombindingtothelysineinthefibrinclot.Asalysineanalog,ACA
competitivelyinactivatesplasminbyoccupyingthesiteonplasminthatwouldnormallybindtofibrin.Inasimilar
manner,ACAbindstoplasminogen,sothatwhenactivatedtoplasmin,itcannotattachtofibrin.
WhenACAwasadministeredorallyinadosageof100mg/kgevery4hoursfor5days,astatisticallysignificant
reductionintheincidenceofrebleedingoftraumatichyphemaswasobserved. [5]SystemicACAshouldbeusedin
hyphemasoccupying75%orlessoftheanteriorchamberbecausetheclotmaypersistintheanteriorchamberfor
anincreasedperiodduringadministrationofthedrug.Thecontinuedretentionoftheclotintheanteriorchamber
couldbeapotentialdisadvantagewithlargerGrade4hyphemas.
Inaprospectivestudybytheauthors,aswellas2additionalstudies,patientgroupstreatedwithACAandplacebo
wererandomizedanddoublemasked. [5,18,36,35]IntheACAtreatedgroup,theincidenceofsecondaryhemorrhage
varied34%. [5,18,36,35]Intheplacebotreatedgroup,theincidencewas2833%.ACAinadosageof50mg/kg
every4hoursisequallyaseffectiveas100mg/kgevery4hours,orally,for5days. [18]ThetotaldosageofACA
shouldnotexceed30gramsperday.
SystemicACAshouldnotbeusedinpatientswhoarepregnantorthosewithrenalorhepaticinsufficiency.
SincesystemicACAsignificantlyreducestheincidenceofsecondaryhemorrhage,atopicalpreparationcould
decreasetheincidenceofadverseeffects.Byconcentratingthedrugintheaqueoushumor,atopicalpreparation
woulddecreasethesystemicconcentrationofACAassociatedwithmanyoftheadverseeffects.
ForsystemicallyadministeredACAtobeeffective,itmustpenetrateintotheanteriorsegmentinsufficient
concentrationtoretardfibrinolysis.TodirectlydeterminetheconcentrationofACAintheaqueoushumorfollowing
systemicadministration,usingananimalmodel,theauthorscomparedplasmaandaqueoushumorconcentrations
ofACAfollowingintravenous(IV)administrationof50mg/kgand100mg/kg,aswellasafterconstantinfusionof
25mg/kg/h. [37]AfterIVadministration,plasmalevelswere10foldhigherthanlevelsintheaqueoushumor.
AntifibrinolyticactivitycorrelateddirectlywithACAconcentrationinplasmaortheaqueoushumor.Thetimetoclot
dissolutionwasgreatest(2.5timescontrol)whentheACAconcentrationintheaqueoushumorreached3035
mg/dL,which,thus,becamethetargetconcentrationtoachievewithtopicaltherapy.
Theauthors'longrangegoalistoimprovethemanagementofhyphemabydecreasingtheincidenceofsecondary
hemorrhageusingtopicaldrugtherapythatismoreeffective,lesstoxic,andbetteracceptedbybothpatientsand
ophthalmologiststhanthecurrentlyavailableoraltherapywithACA.
SeventopicalpreparationscontainingACAwerestudiedtoassesswhichcoulddelivertherequiredamountofACA
intotheaqueoushumor. [38]ThegreatestACAconcentrationswereobtainedusingeitherpolyvinylalcoholor
carboxypolymethylene(CPM),51mg/dLand58mg/dL,respectively.Thelatterhadalongerdurationofaction.
Usinganexperimentalmodelforhyphema,ACAinCPMwasappliedtopicallyevery6hoursfor6daysoruntila
secondaryhemorrhageoccurred. [39]Comparedtonotreatmentortheadministrationofaplacebo(eg,vehicle
withoutACA),topicalapplicationofACAsignificantlydecreasedtheincidenceofrebleedsfrom33%to10%(P<
0.05).Noocularadverseeffectsoccurredaftertopicalapplicationofeitherformulation.
Additionalstudieshavebeenperformedtooptimizetheconcentrationofthevehicleandthedrug. [40]Theoptimal
combinationis30%ACAto2%CPM.However,thiscombinationdidnotleadtoanincreaseinthedurationof
actionusinghyaluronicacid(Healon)orcollagenshieldsasadepot. [41]Thegelisadministeredinaglasssyringe4
timesperdayfor7days.Thegeliswelltoleratedbypatients,includingchildren.
Studiesof25%ACAhavenotseenasignificantbenefitinreducingrebleedingratesandincreasedthetimetoclot
resolution. [42]However,astudyconcludedACAwasbeneficialintreatingpatientswithhyphema. [43]
Theauthorsestablishedaprospective,multicenter,doublemasked,randomizedclinicaltrialcomparingoraland
topicalACA. [44]
Inthetrial,64patientswithtraumatichyphematreatedwithtopicalorsystemicACAwerecomparedwith54control
patientswithhyphema.Comparedwiththecontrolgroup,topicalandsystemicACAwerestatisticallysignificantin
preventingsecondaryhemorrhage.Only3%(2/64)ofthepatientswhoreceivedtopicalACA(35patients)or
systemicACA(29patients)hadsecondaryhemorrhage,comparedwith22%(12/54)ofthecontrolgroup(P=0.002).
Finalvisualacuitywas20/40orbetterin30patients(86%)inthetopicalACAgroup,comparedwith23patients
(43%)inthecontrolgroup(P=0.001).Finalvisualacuitywas20/40orbetterin20patients(69%)inthesystemic
ACAgroup,comparedwith23patients(43%)inthecontrolgroup(P=0.04).Afinalvisualacuityof20/40orbetter
wasregainedby86%ofpatientsinthetopicalACAgroup,comparedwith69%ofpatientsinthesystemicACA
group. [44]
TopicalACAappearstobeasafe,effectivetreatmenttopreventsecondaryhemorrhageinpatientswithtraumatic
hyphema.ItisaseffectiveassystemicACAinreducingsecondaryhemorrhage,andnosystemicadverseeffects
wereobservedwithtopicaluse.TopicalACAprovidesaneffectiveoutpatienttreatmentfortraumatichyphemas.
AlthoughnotapprovedforophthalmicuseintheUnitedStates,anotherlysineanalog,tranexamicacid,alsohas
antifibrinolyticproperties.Inaseriesofchildrentreatedwithtranexamicacid(25mg/kg/d),theincidenceof
secondaryhemorrhagewassignificantlyreduced. [45]LikeACA,tranexamicacidhasbeenassociatedwithnausea,

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vomiting,andhypotension.UnlikeACA,tranexamicacidisassociatedwithvisualabnormalities,whichcould
complicatetheophthalmologicevaluationofthepatient.Inaddition,somepatientsinthisstudyweretreatedwith
otherdrugs,includingtopicalsteroids.Onestudyfoundthattranexamicacidwasbetterthanoralsteroidsin
preventingrebleedingrates. [46]Ametaanalysisofhyphemaliteraturedeterminedantifibrinolyticshadasignificant
impactonhyphemarebleeding. [47]Theauthorssuggestedantifibrinolyticsuseinpatientsathighriskforassociated
hyphemacomplications.
Otherinvestigatorshavesuggestedthatsystemicsteroidsdecreasetheincidenceofsecondaryhemorrhage.Initial
studiessupportingthisclaimwereneitherrandomizednordoublemasked. [32,48]In1980,arandomized,double
masked,prospectivestudybySpoorandassociatesobservedasecondaryhemorrhagerateof20%incontrolsand
13%intreatedpatients,whichwasnotstatisticallysignificant. [17]In1991,Farberandcolleaguescompared
treatmentwithoralACAwithoralprednisoneinawellcontrolledtrial. [49]Theirstudysuggestedthatbothdrugs
decreasetheincidenceofsecondaryhemorrhagebyasimilaramount,albeitbydifferentmechanisms.Becauseof
thesmallnumberofrebleeds,theconfidencelimitswerelargeandmayhavemaskedarealdifference.
Otherstudieshaverecommendedoralsteroidscombinedwithtraditionaltreatmentstoreducerebleedingrates. [46,
31]Arandomized,comparativestudyofACAversusoralsteroidsfoundnosignificantdifferenceintheoutcomes
betweenthe2treatments. [49]
Themajordifficultywiththisstudywasthatcontrolswerenotused.Thelackofatruecontrolpopulationis
unfortunateincomparingthe2groups.Inaddition,thestudyexcludedallpatientswithsicklecelltrait.These
patientsareonegroupthatshouldbeconsideredforsystemicACAorsystemiccorticosteroidtreatment.Inaddition,
patientswithgastriculcerordiabetesmellitusandthosewhowereintoxicatedorhadbleedingwereexcluded.The
modeofactionofprednisoneisunclearandmayberelatedtoanantiinflammatoryinfluenceontraumatizedblood
vesselswithreducedengorgementandapropensityforrebleeding.Additionalrandomizedstudieswithcontrols
wouldbeextremelyhelpfulindeterminingwhetherornotasignificantreductionofsecondaryhemorrhageoccurs
withsystemicprednisoneincomparisonwithsystemicACA.
Somestudieshaveinvestigatedtheapplicationofintracameraltissueplasminogenactivator(tPA)inthe
managementoftraumatichyphema. [50]However,thesestudieshavebeenneitherlargenorrandomized.Apotential
problemwithtPAistheassociatedriskofrebleedingoftheinitialwound.
ApplicationoftPAhasbeenconsideredinresolvinghyphemasthateitherfailtoclearspontaneouslyorare
associatedwithmalignantintraocularpressure, [51]althoughtheactualtimingoftPAadministrationfromtheinitial
injuryhasyettobedetermined.
Topicalantiglaucomatousmedicationsusuallylowerintraocularpressure.Withtheadventofnewerglaucoma
modalities,initiatingtherapyincrementallywithbrimonidinetartrate(Alphagan,Allergan),followedbylatanoprost
(Xalatan,Pharmacia)andtimololmaleate(TimopticXE,Merck),isrecommended.Ifintraocularpressureisstill
elevated,atopicalcarbonicanhydraseinhibitorshouldbeadded.Inpatientswithsicklecelltraitorsicklecell
disease,methazolamideandtopicalbetablockersshouldbesubstituted. [8,52]
Ifintraocularpressureisstilluncontrolled,systemicmedicationshouldbegivenduringtheacutephaseofthe
hyphema.Acetazolamide(20mg/kg/d)maybeadministeredin4divideddosesforintraocularpressureofgreater
than22mmHg.However,acetazolamidecanincreasetheconcentrationofanteriorchamberascorbate,lowerthe
pHofhumanplasma,andexacerbatesicklingoferythrocytes.Therefore,methazolamide(10mg/kg/d),
administeredin4divideddoses,ispreferredinpediatricpatientswithsicklecelltraitorsicklecelldisease. [5,23]
Osmoticagents(preferablymannitol)shouldbeconsideredforintraocularpressureabove35mmHginspiteof
topicalmedications.Orallyadministeredglyceroliseffectivehowever,nauseaandvomitingareoftenassociated
withitsadministrationinpatientswithelevatedintraocularpressure.Mannitolisadministeredintravenously,1.5g/kg
(usuallyina10%solution),overaperiodofapproximately45minutes.Thisagentmaybegiven2timesaday(or
every8hoursinpatientswithextremelyhighpressure)inattempttokeeptheintraocularpressurebelow35mmHg.
Renaloutput,bloodureanitrogen,andelectrolytevaluesshouldbemonitoredinallpatientsinwhomsuchtherapy
iscontinuedforseveraldays.

OutpatientVersusHospitalization
Withincreasingemphasisoncostcontainment,outpatientmanagementofhyphemahasbecomemorepopularin
recentyears.Severalstudieshavedemonstratednosignificantdifferenceinfinalvisualacuitiesinpatientswith
smallerhyphemastreatedathomeorthosetreatedinhospitals. [53,41,54,55,35,56]
Microhyphemascanbetreatedonanoutpatientbasis,unlesssecondaryhemorrhageoccursorelevatedintraocular
pressureisuncontrolled.Patientswithtraumatichyphemaoccupyinglessthanonethirdoftheanteriorchambercan
betreatedonanoutpatientbasiswithsystemicortopicalACA.Ifthehyphemaoccupiesmorethanonethirdofthe
anteriorchamber,intraocularpressureiselevatedbeyond30mmHg,orboth,hospitalizationisrecommended.The
decisiontohospitalizealsodependsonthecooperationofthepatient,familymembers,andtheextentofocular
injury.Foroutpatients,dailyocularexaminations,includinganevaluationoftheamountofhyphemaandintraocular
pressure,shouldbeperformed.Dailyophthalmicsketchesarehelpfulinestimatingtheamountandtherateof
resolutionorrebleeding.Applanationtonometrymustbeperformedatleastoncedailyandtwicedailyinpatients
withelevatedintraocularpressures.
Minimalbloodstainingisoftendifficulttodetectagainstabackgroundofbloodintheanteriorchamber.Undersuch
circumstances,thecorneaoftenassumesayellowishcast,whichisreflectedfromtheyellowishfibrinouscoagulum
intheanteriorchamber.Themosttypicalearlysignofcornealbloodstainingisthepresenceoftinyyellowish
granulesthatinitiallyappearintheposteriorthirdofthecornealstroma.Anadditionalfindingisalackofdefinition
orablurredappearanceoftheordinarilysharplydefinedfibrillarstructureoftheinvolvedcornealstroma.Thelatter
isindependentoftheyellowishcolortransmittedtothestromabythecontentsoftheanteriorchamber.
Theauthorshavefoundthissigntobeusefulinrecognizingtheveryearlystagesofcornealbloodstaining.These
biomicroscopicsignsofcornealbloodstainingusuallyprecedegrossstainingbyonly2436hours.Surgicaltreatment
inthisearlystagemaypreventgrossstaining,andthecorneamayclearin46months.However,oncegrossly
visiblestainingdevelops,manymonthsmayelapsebeforeclearingiscomplete.

SurgicalIntervention
Generally,medicalmanagementseemstoproducethebestvisualresultsforpatientswithlessthantotal
hyphemas.Certainly,othercausesofinflammationorbleedingshouldberuledout,particularlywhenthehistoryof
traumaisquestionable. [57]
Forseveralreasons,surgicalmanagementisfraughtwithcomplication. [35]First,surgeryischosenforthemost
severepresentationsofhyphema,thusselectingoutthemostdifficultcases.Surgicalinterventionisrarelyindicated
forhyphemasthatoccupylessthanonehalfoftheanteriorchambertheselesserhyphemas(eitherprimaryor
secondary)usuallyresolvespontaneouslyunderanymedicalregimenandrequirenosurgicalintervention.

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In2prospectiveseriestotaling196patients,nocornealbloodstainingoropticatrophywasnotedinhyphemasof
50%orless. [5,9]Cornealbloodstaining,withrareexceptions,onlyoccursinpatientswithhyphemasthataretotalat
sometimeduringtheircourse.Theresultsofsurgicalevacuationtoimprovesecondaryglaucomainsmall
hyphemas(75%orless)aredisappointing.Theocularhypertensionintheseinstancesresultsmorefrequentlyfrom
damagetothetrabecularstructuresthanfrompluggingbyredcellsandfibrin.Surgicalevacuationinthese
instancesmayproduceonlytemporarypostsurgicalhypotony,witharapidreturntopreoperativeintraocular
pressure.
Theauthorsbelievethatmosthyphemas,includingtotalhyphemas,shouldbemedicallytreatedforthefirst4days.
Spontaneousresolutionofthehyphemaoccursquiterapidlyduringthisperiod,andthesecaseshavethebest
prognosis.Inoneseriesof20eyeswithtotalhyphemas,4ofthese20eyes(20%)clearedsufficientlybyday4to
ruleoutsurgery. [22]Anadditional4eyesresolvedspontaneouslyonmedicaltreatmentoveralongerperiod.
Surgicalinterventionisusuallyindicatedonorafterthefourthday.Overall,indicationsforsurgicalinterventionare
outlinedbelow. [5,22]
Fourdaysafteronsetoftotalhyphema
Microscopiccornealbloodstaining(atanytime)
Totalhyphemawithintraocularpressuresof50mmHgormorefor4days(topreventopticatrophy)
Totalhyphemasorhyphemasfillinggreaterthan75%oftheanteriorchamberpresentfor6dayswith
pressuresof25mmHgormore(topreventcornealbloodstaining)
Hyphemasfillinggreaterthan50%oftheanteriorchamberretainedlongerthan89days(toprevent
peripheralanteriorsynechiae)
Inpatientswithsicklecelltraitorsicklecelldiseasewhohavehyphemasofanysizethatareassociatedwith
intraocularpressuresofgreaterthan35mmHgformorethan24hours
Ifintraocularpressureremainselevatedat50mmHgormorefor4days,surgeryshouldnotbedelayed.Onestudy
notedopticatrophyin50%ofpatientswithtotalhyphemaswhensurgerywasdelayed.Cornealbloodstaining
occurredin43%ofpatients. [58]
Patientswithsicklecellhemoglobinopathiesandeventhosewithsicklecelltraitrequiresurgicalinterventionif
intraocularpressureisnotcontrolledwithin24hours. [5,23]
Surgeryforpatientswithhyphemashouldbecautiouslyapproached.In2seriesinvolving196patients,surgerywas
performedinonly14patients(7.1%). [5,9]Risksofsurgeryincludedamagetothecornealendothelium,thelens,
and/ortheirisprolapseoftheintraocularcontentsrebleedingandincreasedsynechiaeformation.Withthe
exceptionofpatientswithsicklecelltrait,nopatientsintheseseriesrequiredsurgeryifthehyphemaoccupiedless
than50%oftheanteriorchamber.Totalhyphemaevacuationbyvitrectomyinstrumentation,peripheraliridectomy,
andtrabeculectomyhasbeenrecommended.
Generally,theauthorsrecommendthetypeofsurgicalinterventionwithwhichthesurgeonismostfamiliar.
Hyphemasurgeryshouldbeprecededbyintravenousacetazolamideandmannitoliftheintraocularpressureis
elevated.Theoperationshouldbeperformedundergeneralanesthesiainallpatients.Theoperatingmicroscope
shouldbeusedinallinstances.Presently,the4majorapproachesincludethefollowing:
Hyphemaevacuationwithclosedvitrectomyinstrumentation
Paracentesis
Irrigationandaspirationthroughasmallincision
Clotirrigationwithtrabeculectomy
Currently,thepreferredtechniqueisevacuationofthehyphemawithvitrectomyinstrumentation.Theinitialclear
cornealincisionismadewithadiamondblade.Toavoidboththeirisandthelens,thebladeisorientedandpushed
intotheanteriorchamberinsuchamannerthatitisparalleltotheplaneoftheiris.A20gaugeOcutomeorsimilar
guillotineinstrument,attachedtoaninfusionlineofbalancedsaltsolutionplus(BSSPlus),isgentlyplacedintothe
anteriorchamber.ThebottleofBSSPlusshouldbe3040cmabovetheeyetomaintainnormalintraocular
pressure.WiththeOcutomecuttingporthalfopenandtheinfusionlineinplace,irrigatingandaspiratingfreeblood
fromtheformedclotarepossible.Thesuctionmodeisinitiallysetat4,andthecuttingspeedissetat150forthe
procedure.Ananteriorchambermaintainercanhelpstabilizefluctuationsinintraocularpressureduringclot
evacuation. [59]
Extremecareisrequiredtoavoidanycontactwiththeiris,thelens,orthecornealendothelium.Directingthe
guillotineportanteriorlyandkeepingtheportinviewatalltimesgenerallyavoidsintraoperativeuvealtissueinjury.
Thisoperativeprocedureisusedtoremovethecentralportionoftheclot.Removingtheentireclotintheperiphery
oftheanteriorchamberisnotnecessary.
Ifasecondaryhemorrhageoccursduringtheoperativeprocedure,theauthorsrecommendtamponadeofthe
bleedingbyelevationoftheinfusionbottletoapproximately70cmabovetheeyeforseveralminutes.Ifthe
bleedingcontinues,fillingtheanteriorchamberwithanairbubbleafterevacuatingtheclotishelpful.Ifbleeding
persists,bimanualbipolardiathermyisextremelyhelpfulwhenthebleedingsiteisvisible. [60]Attheendofthe
surgicalprocedure,fillingtheanteriorchamberwithanairbubbleishelpful.Thisalsohelpstocontrolanysecondary
bleeding.Thecornealincisionisclosedwithtwo100nylonsutures.Theresponseinloweringintraocularpressure
withtheOcutomeinstrumentationhasbeenquitesuccessful.Eacheyeoperatedonwiththistechniquehasshown
aninitialdecreaseinintraocularpressureassociatedwiththesurgery.
Paracentesiscauseslittlesurgicaltraumaandrelievestheelevatedintraocularpressure.Paracentesisisespecially
beneficialinpatientswithsicklecelltraitorsicklecelldisease.However,thedecreaseinintraocularpressuremay
betransient,andappreciablereductionmaynotoccurintheamountoftheformedclot.
Irrigationbyasingleordoubleneedletechniquehastheadvantageofasmallincision.Theauthorspreferusinga
diamondbladeandenteringatthe1o'clockpositionintherighteyeandatthe11o'clockpositioninthelefteye.
Theentryshouldbethroughclearcornea.Theirrigatingneedleshouldextendjustthroughthecornealendothelium,
andaslowpushpullmaneuverwiththesingleneedletechniquewashesouttheerythrocytesfromtheanterior
chamberclot,oftenleavingthefibrinmatrix.Toreducethelikelihoodofrebleedingduringtheoperativeprocedure,
careshouldbeundertakennottoproduceviolentalterationsintheanteriorchamberpressure.Ifrebleedingdoes
occur,anairbubblecanbeeffectivelyintroducedfortamponade.Aftera5minutewait,irrigationmaneuverscanbe
resumed.Usingthesingleordoubleneedletechnique,thesurgeonmustbeparticularlycarefultohavedirect
visualizationoftheanteriorchamber.
Thistechniquehassomedisadvantages.Sometimes,maintainingthepositionoftheneedletipintheanterior
chamberduringtheprocedureisdifficult.Ahazardoussituationiscreatedwhenthecollarbuttontypeofformedclot
occupiesboththeanteriorandposteriorchambers.Thisproducespupillaryblockwithanteriordisplacementofthe
irislensdiaphragm.
Generally,trabeculectomyisnotusedinsmallerhyphemas.However,inpatientswithtotalhyphema,
trabeculectomywithperipheraliridectomyshouldbeconsidered.Trabeculectomyisperformedwithgentleirrigation
oftheanteriorchamberhyphema.Thissurgeryisrelativelysafeandshouldbeperformedearlyforpatientswith

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totalhyphemaunlesstheelevatedintraocularpressureismedicallycontrolledandresolutionofthehyphemais
clearlyimminent.
Theauthorscurrentlyperformtrabeculectomyonpatientswithtotalhyphemapersistingtoday4andfinditsuperior
toclotevacuation.Severalpatientsreferredtotheauthors'institutionhavehadattemptsatclotevacuation.One
patientsustainedcompleteiridodialysisrelatedtoattemptedclotevacuation.Inaddition,theauthorshavetreated
otherpatientswhohavebeenreferredafteropticatrophydevelopedwithtotalhyphemas.
Whentrabeculectomyisperformed,theauthorsuseapartialthicknesslamellartechnique.Superficialepiscleral
vesselsarecoagulatedwiththebipolarcautery.Asuperficiallamellarflapisdevelopedthroughonethirdscleral
thickness,creatinga3X3mmtrapdoorhingedatthelimbalarea.A1X4mmwindowthroughthescleralroot
andthetrabecularmeshworkintotheanteriorchamberisfashionedwithadiamondknife.Peripheraliridectomyis
performed,followedbygentleirrigationoftheclotintheareaofthetrabeculectomysite.Two100nylonscleralflap
suturesareusedtoclosethetrabeculectomysite.FirsttheTenoncapsuleandthentheconjunctivaareclosedwith
arunning80or90Vicrylsutureinalayered,anatomicalfashion.Oncetheconjunctivahashealed,thenylon
scleralsuture(s)canbelaseredtoopenupthetrabeculectomysite(whennecessary).Thistechniquehasbeen
invaluableindifficulttotalhyphemacases.
TopicallyappliedmitomycinCmaybeausefuladjunctinthepreventionoflongtermtrabeculectomyfailure,
particularlyinpatientswithtraumaand,therefore,apredispositiontoinflammation.
Becauseeachofthesesurgicalprocedureshasitsownsetofcomplications,thesurgeonshouldapproacheach
patientwithcautionandindividualizethesurgicalstrategy.Postoperativecareshouldincludemeticulouscontrolof
nauseaandemesistoavoidsignificantfluctuationsinintraocularpressure.
Postoperativehyphemasmaybeseenatthetimeofsurgeryorwithinthefirst23daysaftersurgery.Ifbleedingis
identifiedintraoperatively,itmustbeidentifiedandcoagulatedifitdoesnotceaseonitsown.Thesurgeoncan
reducepostsurgicalhyphemasbycreatinginternalsclerostomyasanteriorlyaspossibletoreducebleedingduring
filtrationsurgery.Inuveitisglaucomahyphema(UGH)syndromeassociatedwitharchaicdesignanteriorchamber
IOLsandsulcusposteriorchamberIOLs,thetreatmentmayrequireremovalofthelensthatiscausingtheproblem
andreplacingitwithanotherlens.

ContributorInformationandDisclosures
Author
JohnDSheppardJr,MD,MMScProfessorofOphthalmology,MicrobiologyandMolecularBiology,Clinical
Director,ThomasRLeeCenterforOcularPharmacology,OphthalmologyResidencyResearchProgramDirector,
EasternVirginiaMedicalSchoolPresident,VirginiaEyeConsultants
JohnDSheppardJr,MD,MMScisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanSocietyforMicrobiology,AmericanSocietyofCataractandRefractiveSurgery,
AmericanUveitisSociety,andAssociationforResearchinVisionandOphthalmology
Disclosure:Nothingtodisclose.
Coauthor(s)
EricRCrouch,MDAssociateProfessorofOphthalmology,EasternVirginiaMedicalSchoolAssistant
ProfessorofPediatrics,Children'sHospitalofTheKing'sDaughtersConsultingStaff,VirginiaPediatricEye
Center
EricRCrouch,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanAcademyofPediatrics,AmericanAssociationforPediatricOphthalmologyandStrabismus,and
AmericanCollegeofSurgeons
Disclosure:Nothingtodisclose.
PatriciaBWilliams,PhDProfessor,DepartmentsofOphthalmologyandPharmacology,Director,ThomasR
LeeCenterforOcularPharmacology,EasternVirginiaMedicalSchool
PatriciaBWilliams,PhDisamemberofthefollowingmedicalsocieties:AmericanCollegeofClinical
Pharmacology,AmericanHeartAssociation,AmericanSocietyforPharmacologyandExperimentalTherapeutics,
andAssociationforResearchinVisionandOphthalmology
Disclosure:EyeRxReserach,Inc.OwnershipinterestConsultingOcuCureTherapeutics,Inc.Consultingfee
Consulting
EarlRCrouch,Jr,MD,FACSChairmanandProfessor,DepartmentofOphthalmology,AssociateProfessor,
DepartmentofPediatrics,EasternVirginiaMedicalSchool
EarlRCrouch,Jr,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanAcademyofPediatrics,AmericanCollegeofSurgeons,AmericanMedical
Association,AssociationforResearchinVisionandOphthalmology,NorfolkAcademyofMedicine,Pan
AmericanAssociationofOphthalmology,PhiBetaKappa,andSouthernMedicalAssociation
Disclosure:Nothingtodisclose.
ShobitRastogi,MDAssistantProfessorOfOphthalmology,StateUniversityofNewYorkDownstateEye
Center,DownstateMedicalCenter
ShobitRastogi,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanGlaucomaSociety,andAmericanSocietyofCataractandRefractiveSurgery
Disclosure:Nothingtodisclose.
EnriqueGarciaValenzuela,MD,PhDClinicalAssistantProfessor,DepartmentofOphthalmology,University
ofIllinoisEyeandEarInfirmaryConsultingStaff,VitreoRetinalSurgery,MidwestRetinaConsultants,SC,
ParksideCenter
EnriqueGarciaValenzuela,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanSocietyofRetinaSpecialists,AssociationforResearchinVisionandOphthalmology,
RetinaSociety,andSocietyforNeuroscience
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
JackLWilson,PhDDistinguishedProfessor,DepartmentofAnatomyandNeurobiology,Universityof
TennesseeHealthScienceCenterCollegeofMedicine

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JackLWilson,PhDisamemberofthefollowingmedicalsocieties:AmericanAssociationofAnatomists,
AmericanAssociationofClinicalAnatomists,andAmericanHeartAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
ChristopherJRapuano,MDProfessor,DepartmentofOphthalmology,JeffersonMedicalCollegeofThomas
JeffersonUniversityDirectoroftheCorneaService,CoDirectorofRefractiveSurgeryDepartment,WillsEye
Institute
ChristopherJRapuano,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyof
Ophthalmology,AmericanOphthalmologicalSociety,AmericanSocietyofCataractandRefractiveSurgery,
ContactLensAssociationofOphthalmologists,CorneaSociety,EyeBankAssociationofAmerica,and
InternationalSocietyofRefractiveSurgery
Disclosure:AllerganHonorariaSpeakingandteachingAllerganConsultingfeeConsultingRPSOwnership
interestOtherBausch&LombHonorariaSpeakingandteachingBausch&LombConsultingfeeConsulting
TearScienceConsultingfeeConsultingNicoxConsultingBioTissueHonorariaSpeakingandteaching
RalphGarzia,ODAssistantDeanforClinicalandAcademicPrograms,AssociateProfessor,Collegeof
Optometry,UniversityofMissouriatStLouis
RalphGarzia,ODisamemberofthefollowingmedicalsocieties:AmericanAcademyofOptometryand
AmericanOptometricAssociation
Disclosure:Nothingtodisclose.
ChiefEditor
HamptonRoySr,MDAssociateClinicalProfessor,DepartmentofOphthalmology,UniversityofArkansasfor
MedicalSciences
HamptonRoySr,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOphthalmology,
AmericanCollegeofSurgeons,andPanAmericanAssociationofOphthalmology
Disclosure:Nothingtodisclose.

References
1. MorrisDS.Ocularblunttrauma:lossofsightfromanicehockeyinjury.BrJSportsMed.Mar
200640(3):e5discussione5.[Medline].[FullText].
2. ListmanDA.Paintballinjuriesinchildren:morethanmeetstheeye.Pediatrics.Jan2004113(1Pt1):e15
8.[Medline].
3. SoohooJR,DaviesBW,BravermanRS,EnzenauerRW,McCourtEA.Pediatrictraumatichyphema:a
reviewof138consecutivecases.JAAPOS.Nov82013[Medline].
4. KentJS,EidsnessRB,ColleauxKM,etal.Indoorsoccerrelatedeyeinjuries:shouldeyeprotectionbe
mandatory?.CanJOphthalmol.Aug200742(4):6058.[Medline].
5. CrouchERJr,FrenkelM.Aminocaproicacidinthetreatmentoftraumatichyphema.AmJOphthalmol.
Mar197681(3):35560.[Medline].
6. EdwardsWC,LaydenWE.Traumatichyphema.Areportof184consecutivecases.AmJOphthalmol.Jan
197375(1):1106.[Medline].
7. PodolskyMM,SrinivasanBD.Spontaneoushyphemasecondarytovasculartuftofpupillarymarginofthe
iris.ArchOphthalmol.Feb197997(2):3012.[Medline].
8. HoskinsHD.Secondaryglaucoma.In:HeilmanK,RichardsonKT,eds.Glaucoma:Conceptionsofa
Disease,Pathogenesis,DiagnosisTherapy.PhiladelphiaPa:WBSaunders1978:376.
9. ReadJE,GoldbergMF.Traumatichyphema:Comparisonofmedicaltreatment.TransAmAcad
OphthalmolOtolaryngol.197478:799.
10. RheeDJ,KradO,PasqualeLR.Hyphemafollowingselectivelasertrabeculoplasty.OphthalmicSurg
LasersImaging.SepOct200940(5):4934.[Medline].
11. BlantonFM.Anteriorchamberanglerecessionandsecondaryglaucoma.Astudyoftheaftereffectsof
traumatichyphemas.ArchOphthalmol.Jul196472:3943.[Medline].
12. RecchiaFM,SalujaRK,HammelK,etal.Outpatientmanagementoftraumaticmicrohyphema.
Ophthalmology.Aug2002109(8):146570discussion14701.[Medline].
13. CampbellDG.Ghostcellglaucomafollowingtrauma.Ophthalmology.Nov198188(11):11518.[Medline].
14. PilgerIS.Medicaltreatmentoftraumatichyphema.SurvOphthalmol.JulAug197520(1):2834.[Medline].
15. CrawfordJS,LewandowskiRL,ChanW.Theeffectofaspirinonrebleedingintraumatichyphema.AmJ
Ophthalmol.Sep197580(3Pt2):5435.[Medline].
16. GilbertHD,JensenAD.Atropineinthetreatmentoftraumatichyphema.AnnOphthalmol.Dec
19735(12):1297300.[Medline].
17. SpoorTC,KwitkoGM,O'GradyJM,etal.Traumatichyphemainanurbanpopulation.AmJOphthalmol.
Jan151990109(1):237.[Medline].
18. PalmerDJ,GoldbergMF,FrenkelM,etal.Acomparisonoftwodoseregimensofepsilonaminocaproic
acidinthepreventionandmanagementofsecondarytraumatichyphemas.Ophthalmology.Jan
198693(1):1028.[Medline].
19. SkalkaHW.Recurrenthemorrhageintraumatichyphema.AnnOphthalmol.Sep197810(9):11537.
[Medline].

http://emedicine.medscape.com/article/1190165overview

9/11

12/8/2014

Hyphema

20. WilkerSC,SinghA,EllisFJ.ecurrentbleedingfollowingtraumatichyphemaduetomildhemophiliaB
(Christmasdisease).JAAPOS.200711:6223.[Medline].
21. CrouchERJr.Traumatichyphema.JPediatrOphthalmolStrabismus.MarApr198623(2):957.[Medline].
22. ReadJ.Traumatichyphema:surgicalvsmedicalmanagement.AnnOphthalmol.May19757(5):65962,
6646,66870.[Medline].
23. GoldbergMF.Thediagnosisandtreatmentofsicklederythrocytesinhumanhyphemas.TransAm
OphthalmolSoc.197876:481501.[Medline].
24. MichelsonPE,PfaffenbachD.Retinalarterialocclusionfollowingoculartraumainyouthswithsickletrait
hemoglobinopathy.AmJOphthalmol.Sep197274(3):4947.[Medline].
25. RadiusRL,FinkelsteinD.Centralretinalarteryocclusion(reversibleinsickletraitwithglaucoma.BrJ
Ophthalmol.Jun197660(6):42830.[Medline].
26. BakriSJ,PetersGB3rd.Sympatheticophthalmiaafterahyphemaduetononpenetratingtrauma.Ocul
ImmunolInflamm.Feb200513(1):856.[Medline].
27. MilauskasAT,FuegerGF.Seriousocularcomplicationsassociatedwithblowoutfracturesoftheorbit.Am
JOphthalmol.Oct196662(4):6702.[Medline].
28. RakusinW.Traumatichyphema.AmJOphthalmol.Aug197274(2):28492.[Medline].
29. RochaKM,MartinsEN,MeloLAJr,etal.Outpatientmanagementoftraumatichyphemainchildren:
prospectiveevaluation.JAAPOS.Aug20048(4):35761.[Medline].
30. GharaibehA,SavageHI,SchererRW,GoldbergMF,LindsleyK.Medicalinterventionsfortraumatic
hyphema.CochraneDatabaseSystRev.Dec3201312:CD005431.[Medline].
31. RomanoPE.Systemicprednisolonepreventsrebleedingintraumatichyphema.Ophthalmology.May
2000107(5):8124.[Medline].
32. YasunaE.Managementoftraumatichyphema.ArchOphthalmol.Mar197491(3):1901.[Medline].
33. MilsteinBA.Traumatichyphema.Astudyof83consecutivecases.SouthMedJ.Sep197164(9):10815.
[Medline].
34. SpaethGL,LevyPM.Traumatichyphema:itsclinicalcharacteristicsandfailureofestrogenstoalterits
course.Adoubleblindstudy.AmJOphthalmol.Dec196662(6):1098106.[Medline].
35. KutnerB,FourmanS,BreinK,etal.Aminocaproicacidreducestheriskofsecondaryhemorrhagein
patientswithtraumatichyphema.ArchOphthalmol.Feb1987105(2):2068.[Medline].
36. McGetrickJJ,JampolLM,GoldbergMF,etal.Aminocaproicaciddecreasessecondaryhemorrhageafter
traumatichyphema.ArchOphthalmol.Jul1983101(7):10313.[Medline].
37. LoewyDM,WilliamsPB,CrouchERJr,etal.Systemicaminocaproicacidreducesfibrinolysisinaqueous
humor.ArchOphthalmol.Feb1987105(2):2726.[Medline].
38. AllinghamRR,WilliamsPB,CrouchERJr,etal.Topicallyappliedaminocaproicacidconcentratesinthe
aqueoushumoroftherabbitintherapeuticlevels.ArchOphthalmol.Oct1987105(10):14213.[Medline].
39. AllinghamRR,CrouchERJr,WilliamsPB,etal.Topicalaminocaproicacidsignificantlyreducesthe
incidenceofsecondaryhemorrhageintraumatichyphemaintherabbitmodel.ArchOphthalmol.Oct
1988106(10):14368.[Medline].
40. EhlersWH,CrouchERJr,WilliamsPB,etal.Factorsaffectingtherapeuticconcentrationoftopical
aminocaproicacidintraumatichyphema.InvestOphthalmolVisSci.Nov199031(11):238994.[Medline].
41. MattoxC,WilliamsPB,CrouchER,etal.Aqueoushumorconcentrationsafteruseofreservoirsystemsfor
topicaldeliveryofaminocaproicacid.InvestOphthalmolVisualSci.199132:1293.
42. KarkhanehR,NaeeniM,ChamsH,etal.Topicalaminocaproicacidtopreventrebleedingincasesof
traumatichyphema.EurJOphthalmol.JanFeb200313(1):5761.[Medline].
43. PieramiciDJ,GoldbergMF,MeliaM,etal.AphaseIII,multicenter,randomized,placebocontrolled
clinicaltrialoftopicalaminocaproicacid(Caprogel)inthemanagementoftraumatichyphema.
Ophthalmology.Nov2003110(11):210612.[Medline].
44. CrouchERJr,WilliamsPB,GrayMK,etal.Topicalaminocaproicacidinthetreatmentoftraumatic
hyphema.ArchOphthalmol.Sep1997115(9):110612.[Medline].
45. DeansR,NoelLP,ClarkeWN.Oraladministrationoftranexamicacidinthemanagementoftraumatic
hyphemainchildren.CanJOphthalmol.Jun199227(4):1813.[Medline].
46. RahmaniB,JahadiHR.Comparisonoftranexamicacidandprednisoloneinthetreatmentoftraumatic
hyphema.Arandomizedclinicaltrial.Ophthalmology.Feb1999106(2):3759.[Medline].
47. GharaibehA,SavageHI,SchererRW,GoldbergMF,LindsleyK.Medicalinterventionsfortraumatic
hyphema.CochraneDatabaseSystRev.20111:CD005431.[Medline].
48. RynneMV,RomanoPE.Systemiccorticosteroidsinthetreatmentoftraumatichyphema.JPediatr
OphthalmolStrabismus.MayJun198017(3):1413.[Medline].
49. FarberMD,FiscellaR,GoldbergMF.Aminocaproicacidversusprednisoneforthetreatmentoftraumatic
hyphema.Arandomizedclinicaltrial.Ophthalmology.Mar199198(3):27986.[Medline].
50. LaatikainenL,MattilaJ.Theuseoftissueplasminogenactivatorinposttraumatictotalhyphaema.
GraefesArchClinExpOphthalmol.Jan1996234(1):678.[Medline].
51. StarckT,HoppL,HeldKS,etal.Lowdoseintraoculartissueplasminogenactivatortreatmentfor
traumatictotalhyphema,postcataract,andpenetratingkeratoplastyfibrinousmembranes.JCataract
RefractSurg.Mar199521(2):21924.[Medline].
52. ParverLM,DannenbergAL,BlacklowB,etal.Characteristicsandcausesofpenetratingeyeinjuries
reportedtotheNationalEyeTraumaSystemRegistry,198591.PublicHealthRep.SepOct
1993108(5):62532.[Medline].
53. WaltonW,VonHagenS,GrigorianR,ZarbinM.Managementoftraumatichyphema.SurvOphthalmol.

http://emedicine.medscape.com/article/1190165overview

10/11

12/8/2014

Hyphema

JulAug200247(4):297334.[Medline].
54. CrouchERJr,WilliamsPB.Trauma:rupturesandbleeding.In:TasmanW,JaegerEM,eds.Duane's
ClinicalOphthalmology.Philadelphia,Pa:JBLippincott1993:118.
55. KennedyRH,BrubakerRF.Traumatichyphemainadefinedpopulation.AmJOphthalmol.Aug15
1988106(2):12330.[Medline].
56. WrightKW,SunalpM,UrreaP.Bedrestversusactivityadlibinthetreatmentofsmallhyphemas.Ann
Ophthalmol.Apr198820(4):1435.[Medline].
57. SheppardJD,NozikRA.Practicaldiagnosticapproachtouveitis.In:DuaneTA,JaegerEW,eds.Clinical
Ophthalmology.Vol4.Philadelphia:JBLippincott1989:chap33.
58. WittemanGJ,BrubakerSJ,JohnsonM,etal.Theincidenceofrebleedingintraumatichyphema.Ann
Ophthalmol.Sep198517(9):5256,5289.[Medline].
59. YuT,DahanE,YinZQ,etal.Useofananteriorchambermaintainerinthesurgicalmanagementof
traumatichyphaemas.ClinExperimentOphthalmol.Apr200836(3):2068.[Medline].
60. WeissJS,ParrishRK,AndersonDR.Surgicaltherapyoftraumatichyphema.OphthalmicSurg.Apr
198314(4):3435.[Medline].
61. AlbertDM.PrinciplesandPracticeofOphthalmology.Vol5.1994:14731438,338693.
62. BeckerB.BeckerShaffer'sDiagnosisandTherapyoftheGlaucomas.1989:506,515.
63. DarrJL,PassmoreJW.Managementoftraumatichyphema.AmJOphthalmol.Jan196763(1):1346.
[Medline].
64. DiddieKR,DinsmoreS,MurphreeAL.Totalhyphemaevacuationbyvitrectomyinstrumentation.
Ophthalmology.Sep198188(9):91721.[Medline].
65. McCuenBW,FungWE.Theroleofvitrectomyinstrumentationinthetreatmentofseveretraumatic
hyphema.AmJOphthalmol.Nov197988(5):9304.[Medline].
66. MichelsRG,RiceTA.Bimanualbipolardiathermyfortreatmentofbleedingfromtheanteriorchamber
angle.AmJOphthalmol.Dec197784(6):8734.[Medline].
67. ParrishR,BernardinoVJr.Iridectomyinthesurgicalmanagementofeightballhyphema.Arch
Ophthalmol.Mar1982100(3):4357.[Medline].
68. RitchR,ShieldsMB,KrupinT.TheGlaucomas.1989:648,682,1324.
69. RomanoPE,RobinsonJA.Traumatichyphema:acomprehensivereviewofthepasthalfcenturyyields
8076casesforwhichspecificmedicaltreatmentreducesrebleeding62%,from13%to5%(P<.0001).
BinoculVisStrabismusQ.200015(2):17586.[Medline].
70. SharanS,PainterG,GriggJR.Totalhyphemafollowingpostoperativeenoxaparin(Clexane).Eye.Jul
200519(7):8278.[Medline].
71. ShieldsMB.TextbookofGlaucoma.1998:3567,496,524,526.
72. SpoorTC,HammerM,BellosoH.Traumatichyphema.Failureofsteroidstoalteritscourse:adouble
blindprospectivestudy.ArchOphthalmol.Jan198098(1):1169.[Medline].
73. SternWH,MondalKM.Vitrectomyinstrumentationforsurgicalevacuationoftotalanteriorchamber
hyphemaandcontrolofrecurrentanteriorchamberhemorrhage.OphthalmicSurg.Jan197910(1):347.
[Medline].
74. TerebuhA,LeenM.Ophthalmologysecrets.In:TraumaticGlaucomaandHyphema.1997:151160.
75. WilsonFM.Traumatichyphema.Pathogenesisandmanagement.Ophthalmology.Sep198087(9):9109.
[Medline].
MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/1190165overview

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