Definition

Hyphema is the accumulation of blood in the anterior chamber of the eye. It occurs in about 12 per 100,000 people due to trauma, with 70% of cases involving children. It is most commonly found in males aged 10-20 years, often resulting from sports injuries involving balls (e.g., basketball, football, baseball).

Causes

Hyphema primarily arises from trauma, either blunt trauma or from lacerations. Blunt trauma typically results from a direct impact to the front of the eye, which can damage the iris and nearby structures, including ocular blood vessels. The rupture of these vessels leads to blood accumulation in the anterior chamber of the eye. Various objects, such as stones, toy projectiles, paintball pellets, badminton shuttlecocks, bottle openers, and fists, can cause such trauma. Additionally, hyphema can develop post-surgery; for instance, after cataract surgery, improper placement of an artificial lens can induce fragile new blood vessels on the iris. Laser surgery may also result in hyphema as a side effect.

Hyphema may also occur spontaneously. This often happens due to new blood vessel formation in the eye associated with conditions like diabetes, ocular tumors, uveitis (inflammation of the uveal tract), and vascular abnormalities.

Risk Factor

Activities involving eye protection-less sports increase the risk of hyphema. A history of eye surgery can elevate the risk of hyphema for up to seven days post-operation. Several diseases, primarily blood clotting disorders such as hemophilia, von Willebrand disease, and sickle cell disease, also heighten the risk of spontaneous hyphema. Blood malignancies like leukemia are additional risk factors. Moreover, treatments aimed at thinning the blood, particularly in patients with a history of heart stenting or stroke, can contribute to the risk of hyphema.

Symptoms

The general symptom of hyphema is eye redness. Visual impairment can occur if the blood covers the pupil in the middle of the eye. Visual impairment impairment usually manifests as blurred vision, object distortion, or sensitivity to light. In addition to these symptoms, complaints of eye pain can also appear, especially if intraocular pressure increases.

Diagnosis

Hyphema diagnosis is confirmed by a medical professional who reviews the history of trauma, surgery, medical conditions, and prior spontaneous bleeding incidents. In trauma-induced hyphema cases, the physician first ensures the patient's safety and assesses for other potential injuries. Diagnostic procedures for hyphema often do not require laboratory tests and can be conducted directly by the doctor.

In trauma-related hyphema, the doctor will verify the absence of an open globe injury by examining the eyeball and surrounding skin. Subsequent examinations include visual acuity, light reflex, and intraocular pressure assessments to evaluate the extent of visual impairment. Elevated eye pressure may indicate a disruption in fluid flow within the anterior chamber. An eye specialist might perform gonioscopy to inspect the drainage angle and trabecular meshwork in the anterior chamber. Additionally, slit-lamp or fundoscopic examinations can help determine the hyphema grade and inspect the eye's interior for new blood vessel formation.

Hyphema is classified into four grades:

• Grade I: Blood covers less than one-third of the anterior chamber.
• Grade II: Blood covers one-third to one-half of the anterior chamber.
• Grade III: Blood covers more than half but not the entire anterior chamber.
• Grade IV: Blood completely fills the anterior chamber.

Higher hyphema grades correlate with increased likelihood of elevated intraocular pressure.

For suspected conditions causing spontaneous hyphema, laboratory tests may be required. These tests typically include assessments of blood clotting factors to diagnose conditions like hemophilia or von Willebrand disease and a peripheral blood smear to identify crescent-shaped cells indicative of sickle cell disease. In trauma-induced hyphema cases, a CT scan may be recommended to detect facial fractures or brain injuries associated with the hyphema.

Management

Uncomplicated hyphema is often managed without medication. Eye protection is crucial to prevent further trauma that could exacerbate the condition. Additionally, limiting physical activities and maintaining an upright head position (at least 45 degrees) help the hyphema settle in the lower part of the eye, minimizing visual disturbance. The supine position generally worsens vision impairment due to hyphema. Monitoring is essential during the first few days due to the high risk of rebleeding.

Symptomatic therapy may also be provided. Pain relief can be administered, though certain painkillers may increase the risk of rebleeding. For severe sensitivity to light, eye drops to relax the eye muscles might be prescribed. Elevated intraocular pressure can be managed with eye drops designed to reduce it.

Only 5% of hyphema cases necessitate surgery, usually when the hyphema persists or complications arise. In patients with sickle cell disease, immediate surgery is required if high intraocular pressure remains after 24 hours.

Complications

Hyphema complications pertain to the anterior eye structures. Damage to the trabecular meshwork can lead to increased intraocular pressure. Trauma to the iris or lens may result in unwanted adhesions, impeding the eye's ability to regulate light coming to the eye. Rebleeding, particularly within the first five days, is another complication. Light reflexes may diminish due to blood covering the pupil, and amblyopia (lazy eye) can develop, especially in children.

Prevention

Preventing hyphema involves using protective eyewears during sports or activities involving balls or projectiles. For diabetic individuals, controlling blood sugar through diet, exercise, and medication adherence can prevent new blood vessel formation, reducing the risk of hyphema. However, preventing hyphema in blood disorders remains challenging.

When to see a doctor?

Immediate medical consultation is necessary for eye redness with sudden visual impairment or visual impairment after injury. Hyphema is a potential diagnosis in such cases, but other conditions like acute glaucoma with similar symptoms also require prompt treatment.

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