Hyphema is a collection of blood in the anterior chamber between the cornea and iris, most commonly resulting from blunt trauma to the globe. The majority resolve without treatment, but monitoring for rebleeding (days 3–5), elevated IOP, and corneal blood staining is critical. [1-3]
1. History
- Mechanism of injury: blunt vs. penetrating trauma, projectile type, use of protective eyewear; sports/recreational activities are the most common cause (~40%) [4]
- Timing: when did the injury occur? Any prior episodes of eye trauma?
- Visual symptoms: decreased/blurred vision, floaters, flashers, photophobia — severity correlates with hyphema grade [1]
- Pain: eye pain, headache (may indicate elevated IOP)
- Associated symptoms: nausea/vomiting (suggests elevated IOP) [2]
- Important negatives: no loss of consciousness (rule out concomitant head injury), no sharp object or high-velocity projectile (rule out open globe)
2. Alarm Features
- Total (grade IV) hyphema — "eight-ball" appearance with complete filling of the anterior chamber [1]
- Signs of ruptured globe: teardrop pupil, shallow anterior chamber, extruding uveal tissue, positive Seidel test — treat as open globe until proven otherwise [3]
- Elevated IOP with headache, nausea, vomiting, or firm globe on palpation [2]
- Rebleeding (typically days 3–5): sudden increase in layered blood height, worsening vision [1]
- Corneal blood staining: indicates prolonged contact of blood with endothelium [3]
- Sickle cell trait/disease: even small hyphemas can cause devastating IOP elevation and optic nerve infarction [3][5]
3. Medications
Commonly used treatments
- Topical cycloplegic: Atropine 1% q8h — reduces ciliary spasm, improves comfort, allows posterior segment visualization [2][6]
- Topical corticosteroid: Prednisolone acetate 1% QID — controls traumatic uveitis [2][6]
- Antifibrinolytics (controversial but may reduce rebleed rate):
- Aminocaproic acid (ACA): 50–100 mg/kg PO q4h × 5 days [1]
- Tranexamic acid (TXA): 75 mg/kg/day PO divided TID — may be more potent with fewer GI side effects [7]
- IOP-lowering agents if elevated: topical timolol, brimonidine; oral acetazolamide 500 mg PO BID [2]
- Analgesics: acetaminophen for pain control [2]
Contraindicated/avoid
- NSAIDs (ibuprofen, ketorolac) — prolong bleeding time, increase rebleed risk [2-3]
- Aspirin/salicylates — same mechanism [3]
- Anticoagulants/antiplatelets — hold if clinically safe to do so [8]
- In sickle cell patients: avoid methazolamide (carbonic anhydrase inhibitors that cause systemic acidosis); acetazolamide should be used cautiously; avoid hyperosmotic agents (mannitol) as they promote sickling [9]
ACA cautions: contraindicated in pregnancy, coagulopathies, renal disease; use cautiously in hepatic/cardiovascular disease. Side effects include nausea, vomiting, postural hypotension [1]
4. Diet
- No specific dietary triggers or restrictions
- Hydration: maintain adequate hydration, especially if on acetazolamide (risk of renal stones)
- Avoid alcohol: ethanol alters platelet function and may worsen bleeding [8]
5. Review of Systems
- Ophthalmologic: visual acuity changes, photophobia, eye pain, floaters/flashers
- Neurologic: headache, nausea/vomiting (elevated IOP vs. concomitant head injury), loss of consciousness
- Hematologic: history of easy bruising, prolonged bleeding, known bleeding disorders
- Constitutional: assess for signs of non-accidental trauma (especially in children)
6. Collateral History and Family History
- Sickle cell disease/trait: critical to identify — even sickle cell trait dramatically worsens prognosis; obtain hemoglobin electrophoresis in at-risk populations (African American, Mediterranean, Middle Eastern descent) [1][5]
- Bleeding disorders: hemophilia, von Willebrand disease [8]
- Circumstances of injury: especially in pediatric patients — assess for non-accidental trauma
- Medication use: anticoagulants, antiplatelets, herbal supplements affecting coagulation
7. Risk Factors
- Male sex (78% of traumatic hyphemas) [4]
- Young age: children and young adults predominate; sports/recreation most common cause [4]
- Sickle cell disease/trait: higher risk of elevated IOP, optic atrophy, and need for surgical intervention [5][10]
- African American race: may have higher risk of secondary hemorrhage [8]
- Large initial hyphema (grade III–IV) [11]
- Use of anticoagulants/antiplatelets/NSAIDs [8]
- Hemophilia or other coagulopathies [8]
- Elevated IOP at presentation: predisposes to rebleeding (OR 1.1 per mmHg) [4]
- Age >60 years: associated with poor visual outcome (OR 16.0) [4]
8. Differential Diagnosis
- Open/ruptured globe — must be excluded first; treat as ruptured until proven otherwise [3]
- Spontaneous hyphema (non-traumatic): iris neovascularization (rubeosis iridis, most common cause in adults >60), iris melanoma, juvenile xanthogranuloma, leukemia, herpes zoster keratouveitis [4][8]
- Lens subluxation/dislocation — may coexist with hyphema
- Retrobulbar hemorrhage — proptosis, elevated IOP, restricted motility
- Subconjunctival hemorrhage — benign, blood under conjunctiva not in anterior chamber
- Anterior uveitis with fibrin — can mimic layered hyphema on cursory exam
- Non-accidental trauma (child abuse) — especially in pediatric patients with inconsistent history
9. Past Medical History
- Sickle cell disease/trait — dramatically changes management thresholds [5]
- Bleeding disorders (hemophilia, von Willebrand disease) [8]
- Prior eye trauma or surgery
- Glaucoma — pre-existing angle damage worsens IOP risk
- Anticoagulant/antiplatelet use
- Prior hyphema — angle recession may predispose to late-onset glaucoma
10. Physical Exam
Vital signs: blood pressure (hypertension may worsen bleeding)
Focused eye exam
- Visual acuity: document in each eye — ranges from normal (microhyphema) to near-complete loss (total hyphema) [1]
- Slit-lamp exam: gold standard for diagnosis — look for layered blood, suspended RBCs (microhyphema), clot, fibrin [1]
- IOP measurement: tonometry — elevated IOP is the most common complication (39%). In sickle cell patients, IOP ≥24 mmHg for ≥24 hours may warrant surgical decompression [1][4]
- Pupil exam: assess for traumatic mydriasis, afferent pupillary defect (suggests optic nerve or retinal injury)
- Anterior chamber depth: shallow chamber raises concern for open globe
- Cornea: look for blood staining, lacerations, Seidel test (fluorescein streaming = open globe)
- Fundoscopic exam: dilated exam after hyphema clears to rule out retinal tears, dialysis, detachment, choroidal rupture, vitreous hemorrhage [1]
Grading (commonly used system)
11. Lab Studies
- Sickle cell screen (Sickledex) or hemoglobin electrophoresis: obtain in all at-risk patients (African American, Mediterranean, Middle Eastern descent); only 16.7% of institutions routinely test, but consequences of missing sickle cell trait are severe [5-6]
- CBC with differential: baseline, especially if large hyphema or concern for bleeding disorder
- PT/INR, PTT: if on anticoagulants or suspected coagulopathy
- Type and screen: if surgical intervention anticipated
12. Imaging
- CT orbits (without contrast): if concern for open globe, intraocular foreign body, or orbital fracture — first-line imaging for trauma [3]
- B-scan ultrasound: useful to evaluate posterior segment when fundus view is obscured by hyphema (rule out retinal detachment, vitreous hemorrhage, lens dislocation) — avoid if open globe suspected
- Plain films: limited utility; CT preferred
- MRI: contraindicated if metallic foreign body suspected
- Imaging is not routinely needed for isolated uncomplicated small hyphemas with clear mechanism
13. Special Tests
- Slit-lamp biomicroscopy: essential for grading and monitoring [1]
- Tonometry (Goldmann applanation or Tono-Pen): serial IOP measurements are critical [4]
- Gonioscopy: deferred acutely (risk of globe deformation and rebleed); performed after hyphema resolution to assess angle recession [1]
- Seidel test: fluorescein applied to cornea — streaming indicates corneal perforation/open globe
- Dilated fundoscopic exam: after hyphema clears to evaluate for retinal tears, dialysis, detachment [1]
14. ECG
- Not routinely indicated for isolated hyphema
- Consider if using aminocaproic acid (rare risk of arrhythmias) [1]
- Consider if systemic trauma with hemodynamic instability
15. Assessment
Clinical summary: Hyphema is a vision-threatening emergency requiring prompt ophthalmologic evaluation. The primary concerns are rebleeding (2–38%, typically days 3–5), elevated IOP (39% of cases), and corneal blood staining. [1][4] Approximately 75% of patients achieve visual acuity better than 20/50. [3] Poor prognostic factors include large hyphema, rebleeding (OR 37.5 for poor outcome), worse presenting VA (OR 9.1), and age >60 (OR 16.0). [4]
Severity stratification: Higher-grade hyphemas carry worse prognosis. Sickle cell trait/disease dramatically increases risk — even small hyphemas can cause optic nerve infarction from modest IOP elevations. [3][5]
Complications to consider
- Secondary hemorrhage (days 3–5)
- Elevated IOP / secondary glaucoma
- Corneal blood staining
- Peripheral anterior synechiae
- Optic atrophy
- Angle recession glaucoma (late complication — may present years later)
- Accommodative impairment [1][8]
16. Treatment Plan
Initial stabilization
- Rigid eye shield (Fox shield) — prevents further trauma [2][8]
- Head of bed elevated ≥30° — promotes settling of blood inferiorly [2]
- Activity restriction: quiet ambulation; avoid strenuous activity, Valsalva, bending, near work (reading) [2]
- Avoid emesis: antiemetics as needed — vomiting raises IOP [2]
Medical management
- Atropine 1% topical q8h (cycloplegia) [2][6]
- Prednisolone acetate 1% topical QID [2][6]
- Acetaminophen for analgesia (avoid NSAIDs/aspirin) [2-3]
- Consider antifibrinolytics: systemic TXA reduced rebleed rate (RR 0.33, 95% CI 0.21–0.53); ACA also effective (RR 0.28, 95% CI 0.13–0.60) but with more GI side effects [1][7]
- IOP management if elevated: topical timolol 0.5%, brimonidine; oral acetazolamide 500 mg BID [2]
Sickle cell patients — special considerations
- Lower threshold for surgical intervention — decompress anterior chamber if IOP ≥24 mmHg for ≥24 hours [1]
- Avoid methazolamide and hyperosmotic agents (mannitol) — promote sickling [9]
- Acetazolamide use is debated; some experts avoid all carbonic anhydrase inhibitors in SCD [9]
Surgical indications
- Persistently elevated IOP despite maximal medical therapy [1][3]
- Corneal blood staining [1][3]
- Non-clearing total hyphema [1]
- Sickle cell patients with sustained IOP elevation [5][10]
- Procedure: anterior chamber paracentesis/washout is simplest and safest; trabeculectomy with washout for refractory cases [3][12]
17. Disposition
Admission criteria
- Total (grade IV) hyphema or large hyphema (grade III) [1]
- Sickle cell disease/trait [1][5]
- Elevated IOP not controlled with initial medical therapy
- Rebleeding episode
- Non-compliance concerns (medication adherence, activity restriction, follow-up) [1][8]
- Children at risk for non-accidental trauma
- Coagulopathy or hemophilia [8]
Discharge criteria (outpatient management)
- Small hyphema (grade I–II) without elevated IOP
- Reliable patient/family with ability to comply with activity restriction and medications
- No sickle cell disease/trait
- No coagulopathy [8]
- Ophthalmology follow-up confirmed within 24–48 hours [6]
Specialist consultation
- Ophthalmology: all hyphemas require ophthalmology consultation or referral [2]
- Hematology: if sickle cell disease/trait or bleeding disorder identified [5]
18. Follow Up / Return Precautions
Follow-up timing
- Initial follow-up within 24–48 hours (75% of institutions schedule within 48 hours) [6]
- For uncomplicated cases: days 1, 3, 5, 7, and 14 is sufficient [4]
- Peak rebleed risk is days 3–5 — ensure close monitoring during this window [1]
- Long-term: gonioscopy after hyphema resolution to assess for angle recession; annual IOP checks indefinitely (angle recession glaucoma can develop years later) [1]
Return precautions — instruct patients to return immediately for:
- Worsening or new decrease in vision
- Increasing eye pain or headache
- Nausea/vomiting
- New bleeding or change in blood level in the eye
- Light sensitivity worsening
Patient counseling
- Strict activity restriction for 5–7 days (no sports, heavy lifting, bending, straining)
- Sleep with head elevated ≥30°
- Wear rigid eye shield at all times (including sleep) [2]
- No reading or near work (accommodation moves iris, may worsen rebleed) [2]
- No aspirin, ibuprofen, or NSAIDs [2-3]
- Expected recovery: most small hyphemas resolve within 5–7 days; 75% achieve VA ≥20/50 [3]
References
1. Medical Interventions for Traumatic Hyphema. — Woreta FA, Lindsley KB, Gharaibeh A, et al. The Cochrane Database of Systematic Reviews. 2023.
2. Wilderness Medical Society Clinical Practice Guidelines for Treatment of Eye Injuries and Illnesses in the Wilderness: 2024 Update. — Paterson R, Drake B, Tabin G, Cushing T. Wilderness & Environmental Medicine. 2024.
3. Eye Injuries. — Shingleton BJ. The New England Journal of Medicine. 1991.
4. Epidemiology and Outcomes of Hyphema: A Single Tertiary Centre Experience of 180 Cases. — Iftikhar M, Mir T, Seidel N, et al. Acta Ophthalmologica. 2021.
5. Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014. — National Heart, Lung, and Blood Institute. 2014.
6. Global Current Practice Patterns for the Management of Hyphema. — Miller SC, Meeralakshmi P, Fliotsos MJ, et al. Clinical Ophthalmology. 2022.
7. Comparison of Tranexamic Acid and Prednisolone in the Treatment of Traumatic Hyphema. A Randomized Clinical Trial. — Rahmani B, Jahadi HR. Ophthalmology. 1999.
8. Management of Traumatic Hyphema. — Walton W, Von Hagen S, Grigorian R, Zarbin M. Survey of Ophthalmology. 2002.
9. Reversal of Retinal and Optic Disc Ischemia in a Patient With Sickle Cell Trait and Glaucoma Secondary to Traumatic Hyphema. — Wax MB, Ridley ME, Magargal LE. Ophthalmology. 1982.
10. Clinical Characteristics and Outcomes of Hyphema in Patients With Sickle Cell Trait: 10-Year Experience at the Wilmer Eye Institute. — Mir T, Iftikhar M, Seidel N, et al. Clinical Ophthalmology. 2020.
11. Contemporary Aspects in the Prognosis of Traumatic Hyphemas. — Papaconstantinou D, Georgalas I, Kourtis N, et al. Clinical Ophthalmology. 2009.
12. Trabeculectomy for Traumatic Hyphema With Increased Intraocular Pressure. — Graul TA, Ruttum MS, Lloyd MA, Radius RL, Hyndiuk RA. American Journal of Ophthalmology. 1994.