Further Inpatient Care
- The clot is least adherent to the surrounding tissues on the fourth day following the injury; this is the preferred time for surgery, when it is needed.
- Hyphema may be washed out or removed with a vitrectomy instrument.
- In some cases, a trabeculectomy may be necessary to control intraocular pressure (IOP).
Further Outpatient Care
- Despite clearing the hyphema, IOP may remain high.
- In these cases, perform serial gonioscopic examinations to detect angle recession, synechia, and sustained blood clot.
- Treat the appearance of the optic nerve and visual field.
- Vitreous hemorrhage and retinal breaks might complicate a case even if the hyphema clears.
Inpatient & Outpatient Medications
- If the patient tolerates antiglaucoma medications for controlling IOP, keep these medications.
- As the hyphema clears and IOP decreases, discontinue medications in a stepwise fashion, starting with the one that has the most systemic adverse effects.
Deterrence/Prevention
- Glaucoma can be seen 10 years or after following ocular trauma. Therefore, these patients need to be followed periodically indefinitely. Also see the clinical guideline summary from the US Preventative Services Task Force, Screening for glaucoma: recommendation statement.
Complications
- Corneal bloodstaining is one complication of long-standing hyphema in association with glaucoma.
- Both hemosiderin and hemoglobin collect in the stroma and give the cornea a yellowish appearance.
- It usually spontaneously resolves in years. When there is suspicion of corneal bloodstaining in the early stages, the hyphema should be cleared surgically. Washing out the anterior chamber long after the incident has been found to be useful to clear bloodstaining.
- Anterior segment structures can become difficult to visualize.
- Glaucoma may lead to optic atrophy; this is especially true in patients with sickle cell. Always consider early surgical intervention in resistant cases. A long period of high IOP (ie, 50 mm Hg lasting longer than 5 d) is dangerous.
- The most severe complication of hyphema is not the initial bleed but rather a rebleed, which is usually seen within 72 hours following the initial trauma. The rebleeding rate is 10-20%.
- Hyphema resulting from a rebleed usually is more extensive than that seen with the initial trauma.
- Rebleeding may present as total hyphema with blood filling the entire anterior chamber, often called 8-ball hyphema. Such significant hemorrhages often lead to elevated IOPs and corneal bloodstaining. They also are more likely to require surgical care.
- Peripheral anterior synechia is another complication and is associated with larger hyphemas and longer durations.
Prognosis
- Prognosis depends on the size of the hyphema. Patients with a small-sized hyphema have a good prognosis with simple management and treatment. Patients whose eyes undergo rebleeding have a poor prognosis because they have a larger sized hyphema and are also more likely to have higher IOP.
- Patients who undergo surgery for anterior chamber wash-out or for ocular injury repair following initial trauma also have a poorer prognosis.
- Total hyphema is difficult to treat, and the visual outcome is usually poor.
- In some studies, final vision was found better than 20/50 in almost 75% of all hyphema cases.
Patient Education
- Promote public awareness about wearing goggles in high-risk sports or work environments.
- For excellent patient education resources, visit eMedicine's Eye and Vision Center and Glaucoma Center. Also, see eMedicine's patient education articles Hyphema (Bleeding in Eye), Glaucoma Overview, Glaucoma FAQs, and Understanding Glaucoma Medications.
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