BY WILLIAM TOWNSEND, OD
Jerron, an 11-year old male, presented with a painful red left eye. One of his friends had accidentally struck him in the eye with a buckle. He immediately reported pain and "red vision."
He was seen in our office a few minutes later. Slit lamp exam showed a diffuse hemorrhage in the anterior chamber in the left eye. Tensions by applanation were OD 14mm Hg, OS 21mm Hg.We cyclopleged him with 5% homatropine and prescribed modified best rest and a Fox shield. The next day, acuities had improved to 20/20 OU, and the hyphema had settled out, filling about one-fourth of the anterior chamber. Intraocular pressures were OD 14mm Hg, OS 21mm Hg. By day four his hyphema had totally cleared.
Hyphema is closely associated with trauma and commonly appears in adolescent males. Hyphemas are graded on the depth of blood in the anterior chamber. Patients with blood in less than one-third of the anterior chamber have a better prognosis.
The greatest single risk in hyphema is rebleed, although it is less common in smaller hyphemas. The risk of rebleed is highest in children under 6 and individuals of African origin, especially those with sickle cell trait. About one-third of patients with rebleeds require surgery. Read and Goldberg found an overall 25 percent rebleed rate; 33 percent of eyes that rebleed progress to total hyphema, a serious condition that can lead to corneal blood staining, elevated IOP and glaucoma with accompanying optic nerve damage. Severe elevation of IOP secondary to total hyphema can cause central retinal artery occlusion.
Age is an important consideration in treating hyphema. Children under 6 have a 44 percent risk for rebleed and should be hospitalized when possible. Individuals with small hyphemas and no other risk factors should be treated with modified bed rest and elevation of the head to 30 or 35 degrees to encourage settling of blood in the anterior chamber.
Cycloplegia, once also considered controversial, is now accepted as standard treatment. Atropine ointment or homatropine drops should be instilled after performing applanation tonometry. Cover the eye with a Fox shield or similar device for air circulation and detecting erythropsia (red vision) should a rebleed occur.
Manage high IOPs with systemic carbonic anhydrase inhibitors or topical beta blockers. Control pain with acetominophen or, in severe cases, a narcotic analgesic. Avoid NSAIDS and aspirin. Topical steriods may be reduce inflammation in cases with significant anterior chamber reaction along with the hyphema.
Antifibrinolytic agents have been shown to reduce the likelihood of rebleeds. Crouch and Frenkel showed that hyphema patients treated with oral amin-ocaproic acid (Amicar, Lederle) were 10 times less likely to rebleed than untreated patients. In a later study, Crouch showed that topical Amicar was as effective as the oral medication and lacked side effects such as nausea and vomiting. Topical aminocaproic acid is not currently available.
Even with excellent care, patients do rebleed. Consider referring hyphema patients to an anterior segment and/or glaucoma specialist if IOP is greater than 60mm Hg, total hyphema is present, a 50 percent hyphema does not show improvement after six days, or if patients with sickle cell trait present with IOP greater than 35mm Hg after two days.
Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at firstname.lastname@example.org.