This patient’s clinical presentation and exam findings are consistent with the diagnosis of traumatic hyphema. Other diagnoses to consider include: iris neovascularization, Herpes simplex/zoster iridocyclitis, blood dyscrasias, anticoagulation, and intraocular tumors.
Hyphema is defined as blood in the anterior chamber with or without blood layering in the inferior part of the chamber. Hyphemas are graded I-IV based on the amount of anterior chamber covered by the hyphema (grade I-less than 1/3 of the anterior chamber, grade II- 1/3 to 1/2 of the anterior chamber, grade III-1/2 to nearly total of the anterior chamber, grade IV- total hyphema (if black in color named 8-ball hyphema). Bleeding usually occurs from rupture of ciliary vessels.
Work-up for hyphema should include a detailed history on the type of injury, personal or family history of sickle cell disease, use of anticoagulants, and history of coagulopathy. On exam, FIRST RULE OUT AN OPEN GLOBE. Other important aspects of the exam include documentation of the extent and location of the hyphema, measurement of IOP, and DFE without scleral depression. CT of the orbits can be performed if indicated as in cases of facial/orbital fractures. A B-scan U/S can be considered if there is poor visualization of the posterior pole. African American and Mediterranean patients should be screened for sickle cell disease as they are at risk for increased IOP and vision loss due to trabecular meshwork obstruction by the sickled cells.
In the treatment of hyphema, it is crucial to stress the importance of complete bed rest. Hospitalization may be considered in non-compliant patients. Additionally patients should be instructed to elevate the head of the bed to allow the blood to settle. A shield should be placed over the involved eye at all times. Non-NSAID analgesics should be used for pain relief. Cycloplegics (such as atropine or scopolamine) and topical steroids can be used to treat the associated iritis. If patients have increased IOP, first line therapy is topical beta-blocker. If medical management fails, surgical evacuation of the hyphema may be considered. Indications for surgical evaluation include: corneal stromal blood staining, non-clearing total hyphema and high IOP. The threshold for surgical evacuation is lower in sickle cell patients due to a higher risk of complications.
Patients should be followed daily for the first three days to monitor for rebleeding, resolution of symptoms and decrease in the size of the hyphema. The risk of rebleeding is highest in the 3 – 7 day period post injury and is associated with worse prognosis. Further follow-up depends on the severity of bleeding and other complications. Complications of hyphema include posterior synechiae, peripheral anterior synechiae, corneal blood staining, glaucoma and optic atrophy due to high IOP. Prognosis can be poor to excellent depending on the severity of initial injury. Patients should be followed annually to monitor for development of glaucoma.