Hyphema Glaucoma Clinical Presentation

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. Hyphema may be accompanied by a foreign object in the eye.

Sports injuries, motor vehicle accidents, and work-related injuries are common causes of hyphema.

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.

Asking about the use of blood thinners in addition to alternative medicine, such as ginkgo biloba, is important.

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)

  • Intraocular surgery (during or after): Increased use of angle-based microinvasive glaucoma surgeries such as goniotomy or trabeculotomy procedures has been associated with higher incidence of postoperative hyphemas.

  • 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), as shown in the image below

    Total or 8-ball hyphema.

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• 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. Increased pigmentation of the angle due after ocular trauma has been associated with an increased risk of developing glaucoma. 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.

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

• Spontaneous hyphema associated with anticoagulant treatment, hemophilia, and other blood disorders

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.