eMedicine Specialties > Ophthalmology > Intraocular Pressure

Glaucoma, Hyphema

Author: Inci Irak-Dersu, MD, Assistant Professor, Director of Glaucoma Service, Department of Ophthalmology, University of Arkansas College of Medicine, Jones Eye Institute
Contributor Information and Disclosures

Updated: Dec 28, 2007

Introduction

Background

Hyphema is the collection of red blood cells in the anterior chamber. A microhyphema occurs when the red blood cells are only detectable microscopically. In a macroscopic hyphema (hyphema), a visible layer of red blood cells in the anterior chamber may be detected even without the aid of slit lamp magnification. Complications are more frequently related to hyphema than microhyphema.

Pathophysiology

Trauma is the most common cause of hyphema; consequently, hyphema is often seen in younger patients. A blunt, compressive force acting on the globe creates tears in the ciliary body, iris, and other anterior segment structures. These tears cause shearing of blood vessels, including those that make up the major arterial circle of the anterior segment. Hyphema also may be caused by intraocular tumors, which may be benign or malignant.

Neovascularization of the iris or ciliary body may result in hyphema. This neovascularization can be caused by posterior segment ischemia, which usually is associated with microvascular disease in diabetes. Retinal ischemia also can occur subsequently to retinal arterial or venous occlusion. Another cause of the neovascularization is carotid stenosis, which can lead to ocular ischemia. Hyphema also may be iatrogenic in origin; it can occur any time after intraocular surgery, especially surgery that involves the filtration angle. Certain types of anterior chamber intraocular lenses used after cataract extraction lend themselves to hyphema, especially rigid lenses, which is called uveitis-glaucoma-hyphema (UGH) syndrome.

Corneal bloodstaining results from blood being forced into corneal endothelial cells, thereby "staining" the otherwise clear cornea. Bloodstaining is an ominous sign and often heralds the need for surgical evacuation of the hyphema.

The rise in intraocular pressure (IOP) is related to red blood cells and their byproducts clogging the trabecular meshwork; another cause is direct trauma to the meshwork, which occurs concurrently with the initial trauma.

Secondary angle-closure glaucoma that results from pupillary block may also occur. Pupillary block is seen when the clot completely secludes the pupil/lens interface, thereby blocking the flow of aqueous from the posterior to the anterior chamber.

Frequency

United States

In North America, the incidence of hyphema is 17-20 cases per 100,000 people per year. The rebleeding rate is 10-20%.

Mortality/Morbidity

Most hyphema cases are due to blunt trauma. Less common causes are systemic diseases and following eye surgery. Spontaneous hyphema is quite rare. Morbidity of disease depends on underlying pathology, associated diseases, and risk factors.

Race

The African American population has a higher risk for sickle cell hemoglobinopathy. This group is more likely to have complications of hyphema, including central retinal artery occlusion.

Sex

The male-to-female ratio is 3:1.

Age

The young population is most affected. Approximately 77% are younger than 30 years. The peak incidence is in people aged 10-20 years.

Clinical

History

When a patient presents with a hyphema, the most critical first step is obtaining a thorough history of the trauma.

• The mechanism of the injury and the type of assaulting object must be ascertained.
• It is important to determine if the patient was wearing protective eyewear at the time of the trauma.
• The patient's ethnic origin is important. Sickle cell trait/disease is more common in patients of African and Mediterranean descent.
• A good past medical history needs to be obtained, including sickle cell hemoglobinopathy, diabetes, and herpetic infection.
• Past ocular history, including ocular surgery and laser surgery, is important.

Physical

The ocular examination should start with a thorough evaluation of the ocular adnexa, looking for asymmetry.

• The following points should be considered during an ocular examination:
  • In the presence of traumatic hyphema, always consider the possibility of a coexisting ruptured globe, especially if the IOP is normal or low. If a coexisting ruptured globe is suspected, perform exploratory surgery and defer the remainder of the examination until the patient is in the operating room.
  • Hyphema may be associated with other clinical entities, and the following should be suspected in the absence of trauma:
    • Rubeosis iridis (eg, proliferative diabetic retinopathy, following central or branch retinal vessel occlusion, ocular ischemic syndrome)
    • Surgery (during or after)
    • Iritis (eg, Fuchs heterochromic iridocyclitis, herpes simplex, herpes zoster)
    • Intraocular tumors (eg, juvenile xanthogranuloma, retinoblastoma, malignant melanoma)
    • Iris varix, pupillary microhemangiomas
    • Following laser trabeculoplasty or iridotomy
    • Bleeding disorders
• A full ophthalmic examination includes the following:
  • Visual acuity
  • Begin evaluation of the iris at the pupillary margin and move outward.
    • The examiner should look closely for sphincter tears.
    • Examine the anterior surface of the iris, which is made of stromal tissue for the presence of abnormal vessels.
    • If the angle is nonoccludable, perform dilation in conjunction with cycloplegia.
    • Carefully examine the vitreous cavity for abnormalities.
    • Study the macula, vessels, and periphery.
    • Note any evidence of neovascularization of the disc or elsewhere. In addition, look for evidence of recent or remote vascular occlusion.
  • Pupillary reaction - Evaluation of pupillary responses is mandatory to rule out afferent pupillary damage.
  • Extraocular eye movement - Carefully perform motility and ocular alignment to look for any signs of entrapment.
  • Signs of corneal staining - Focus corneal examination on the presence or absence of bloodstaining.
  • Any previous corneal scar
  • Red or white blood cells in the anterior chamber
  • Macroscopic hyphema can be documented according to the height of the blood clot (in millimeters) in the anterior chamber. Hyphema can also be graded (I-IV) based on the amount of blood clot spacing in the anterior chamber.
    • Grade I: Less than one third of the anterior chamber
    • Grade II: One third to one half of the anterior chamber
    • Grade III: One half to nearly total of the anterior chamber
    • Grade IV: Total hyphema (also called 8-ball hyphema)
  • Anterior segment for signs of inflammation (critical)
  • Iris neovascularization, nodules, and heterochromia
  • Measure IOP by applanation tonometry. Glaucoma is more likely to develop with total hyphema or after rebleeding.
  • Perform dilated fundus examination as soon as the corneal clarity and hyphema allow a view of the fundus after dilation.
    • Note the presence of vitreous and retinal hemorrhage.
    • Document baseline appearance of the optic nerve and color of the neuroretinal rim.
    • If the retina cannot be visualized and if retinal breaks and detachment are suspected, perform ultrasonography earlier.
• Defer gonioscopic examination because it may precipitate rebleeding if hyphema is caused by trauma; otherwise, perform dynamic gonioscopy to look for evidence of abnormal masses or vessels in the filtration angle. Additionally, gonioscopy can help reveal the site of origin of the bleed or a clot in that area. If the patient has an anterior chamber intraocular lens (IOL), gonioscopic examination of the placement of the footplates in the angle should be carefully studied.
• Use an exophthalmometer to look for enophthalmos that is related to the ocular trauma.
• If the patient does not have a history of trauma, examine the carotid arteries for a bruit. This finding may herald ocular ischemic syndrome, as well as neovascularization that leads to hyphema.

Causes

• Trauma is the major cause.
• Other causes include the following:
  • Rubeosis iridis
  • Surgery (during or after)
  • Iritis (eg, Fuchs heterochromic iridocyclitis, herpes simplex, herpes zoster)
  • Intraocular tumors (eg, juvenile xanthogranuloma, retinoblastoma, malignant melanoma)
  • Iris varix, pupillary microhemangiomas
  • Following laser trabeculoplasty or iridotomy
  • Sickle cell disease/trait
  • UGH syndrome

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