Hyphema Glaucoma Treatment & Management

Treatment of microhyphemas in which the intraocular pressure (IOP) is not elevated usually involves limiting activities that cause rapid movements of the globe during the first 72 hours.

Patients who have concurrent elevation of IOP may require topical and oral ocular hypotensive medications to lower the IOP. These patients also require cycloplegia and topical steroids. Non-white patients should all be screened for sickle cell trait or disease because sickling can lead to obstruction of the central retinal artery and profound irreversible visual loss.

Cycloplegics (eg, cyclopentolate tid, atropine qd) are used to treat associated iritis.

Topical steroids (eg, prednisolone acetate) can be used 4 times a day to treat concurrent traumatic iritis.

The use of oral steroids is controversial. Despite their direct antifibrinolytic properties, no clear benefit in resolution of hemorrhage or preventing rebleeding has been noted.

Aminocaproic acid (Amicar), an antifibrinolytic agent, reduces recurrent hyphemas. Intravenous and oral forms are available.

If treatment is started within the first 3 days of the occurrence of a hyphema, aminocaproic acid (50 mg/kg PO q4h for 5 d) has been found to be useful in decreasing rebleeding. However, adverse effects, such as hypotension, nausea, and renal and hepatic toxicity, limit its use. Additionally, in total hyphemas, this drug may delay resorption of blood. In addition, no obvious benefit to improve the final visual outcome has been noted. Although commercially unavailable, topical aminocaproic acid may limit systemic adverse effects.

Another antifibrinolytic agent, tranexamic acid (Cyklokapron), reportedly has fewer adverse effects, particularly gastrointestinal discomfort, than aminocaproic acid, but the oral form is not available in the United States. ^[2] Similar to aminocaproic acid, it does not affect final visual acuity or have associated risks of rebleeding; therefore, it was suggested that antifibrinolytics may be saved for high-risk patients such as sickle cell trait patients. ^[3]

IOP reduction is usually necessary if it is higher than 24 mm Hg in patients with sickle cell or higher than 30 mm Hg in other patients.

The threshold for treating glaucoma has been reduced in patients with sickle cell because of their susceptibility to glaucomatous optic nerve damage and central retinal artery occlusion at even slightly increased pressure. Glaucoma can be treated with topical medications (eg, beta-blockers [Timoptic bid and new generation drops]).

Avoid oral carbonic anhydrase inhibitors, especially acetazolamide (eg, Diamox), in patients with sickle cell trait or disease. These drugs tend to increase sickling of erythrocytes. Methazolamide may be a better choice in this situation (Neptazane 50 mg PO q8h).

Use hyperosmotic agents like intravenous mannitol or acetazolamide for further control.

Supportive treatment

Wearing a metal or hard plastic shield at all times (during the day and at night) is recommended. Patching is recommended when a risk of corneal staining exists; however, measurements should be taken for occlusion amblyopia.

Strict bed rest has not been shown to be beneficial in comparison to mild activity.

Head elevation (up to 30°) helps level the blood inferiorly and keeps the central cornea and pupil aperture clean.

Aspirin should be avoided to prevent rebleeding.

Corneal bloodstaining is an ominous sign, and these cases are often best treated with surgical evacuation of the blood. ^[3] A vitrectomy instrument or an irrigation/aspiration cannula may be used for this purpose. Two clear corneal paracentesis incisions can be used to evacuate the clot. If the IOP has caused some optic nerve damage and the pressure is unlikely to be stabilized with only surgical wash-out, a trabeculectomy can be performed at the same session.

All attempts at treating the elevated IOP with medications should be made prior to surgical wash-out of the hyphema. It is reasonable and helpful to not wash-out the eye until at least 72 hours have transpired to allow for clot formation. The maximum blood clot formation is achieved 4-7 days after trauma. If clot formation has not occurred, opening the eye may simply lead to persistent hemorrhage.

Indications for anterior chamber wash-out are as follows:

• Total hyphema does not resolve in 5 days.

• IOP remains elevated despite the maximum medical treatment. A normal optic nerve can tolerate an IOP as high as 50 mm Hg for 5 days. If the patient had previous optic nerve compromise or a history of sickle cell trait or disease, consider surgical intervention for elevated IOP above 24 mm Hg that lasts beyond 1-2 days.

• Decreasing visual acuity

• Signs of corneal bloodstaining

• Increased risk of synechia formation (ie, hyphema filling more than 50% of the anterior chamber and lasting longer than 8 d)

When the results of sickle cell prep or hemoglobin electrophoresis are positive, consultation with a pediatrician or internist is indicated.

No special diet is required for patients with hyphema.

Instruct patients to keep activity to a minimum during the first 5 days of hyphema to reduce the chances of a rebleed. Although no evidence exists regarding ambulation versus bed rest and whether one is superior to the other in the prevention of rebleeding, limiting activity is wise to avoid new injuries.

A single or binocular patch does not affect the outcome regarding visual acuity or time of rebleed.

Hyphemas in infants and children are difficult to treat because preventing a rebleed is paramount. The importance of limiting a child's activity over the first 72 hours cannot be overemphasized to the caregivers. Watching television from a distance of greater than 10 feet is acceptable because of the minimal eye movement that occurs with viewing a fixed screen at this distance.

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.

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.

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).

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.