Hyphema - Causes, Symptoms, Diagnosis, and Treatment

Introduction

The eyes are the window to our bodies. Eyes see things or create an image through the few layers it possesses. The cornea, iris, lens, and retina are the critical layers of the eye (the outermost layer to the innermost layer). The space between the cornea and iris is called the anterior chamber and is filled with aqueous humor (a clear fluid that nourishes the eye and maintains the intraocular pressure.

Hyphema is when blood gets collected in the eye's anterior chamber, covering most of the iris and pupil(central part of the iris), disrupting the vision wholly or partially. The general causative factor is trauma to the eye, but many other factors are also recorded.

Hyphema and subconjunctival hemorrhage might look the same, but there are a lot of differences, an important one being the grade of pain and location. In some cases, only a tiny blood spot will be seen in an examination called microhyphema. Hyphema eye is highly painful and affects only the central part of the eye. Subconjunctival hemorrhage affects only the white portion of the eye.

What Are the Causes of Hyphema?

The most common cause is trauma - both blunt and penetrating.

• Sports injury.

• Accident in the workplace.

• Fall.

• Airsoft guns.

• Fights.

Less common causes are,

• Neovascularization (abnormal growth of blood vessels).

• Tumors of the eye.

• Medications that cause thinning of blood - are aspirin and warfarin.

• Alcohol consumption.

• Hemophilia (a condition in which blood does not clot due to the lack of clotting factors).

• Uveitis (inflammation of the eye).

• Von Willebrand disease (blood does not clot and is a lifelong condition).

• Myotonic dystrophy (muscle weakness).

• The herpes virus causes eye infections.

• Problems with the artificial intraocular lens.

What Are the Symptoms of Hyphema?

• Blurred vision.

• Complete inability to see from the affected eye.

• Pain.

• Sensitive to light.

• Red-colored vision.

• Evident blood in the front part of the eye.

What Are the Gradings of Hyphema?

The clinical grading system followed for hyphema categorizing is,

• Grade 1 - blood occupies less than one-third of the anterior chamber.

• Grade 2 - blood occupies one-third to one-half of the anterior chamber.

• Grade 3 - blood occupies one-half to less than the total space of the anterior chamber.

• Grade 4 - The total anterior chamber gets filled with blood, and if the blood is dark red, it is called a blackball or 8-ball hyphema.

How to Diagnose Hyphema?

1) Gathering History Before Diagnosis:

Firstly, a case history will be taken where the source of the condition will be evaluated.

The patient will be asked if they had trauma or an accident in recent times. Most of the cases will be because of a trauma to the eye.

In some cases, where there is a spontaneous hyphema, patients will be asked about their medical conditions, like clotting disorders and medications. Sickle cell anemia is the primary consideration, along with aspirin and warfarin (blood-thinning drugs).

The patient will be evaluated for sickle anemia because it causes trabecular meshwork obstruction. The trabecular meshwork is present between the cornea and iris, through which the aqueous humor is drained out. In trabecular meshwork obstruction, the aqueous humor will not drain due to pooling sickled blood cells, and eventually, intraocular pressure gets elevated.

2) Diagnostic Tests:

• Visual Acuity Test: This test is done to assess the vision power of the eyes. The patient will be made to sit 6 feet away from a Snellen eye chart. The chart will have alphabets and numbers from bigger to smaller sizes. The patient will be asked to read the alphabet/numbers to assess their vision.

• Slit Lamp Test: For this test, the doctor will put numbing eye drops in the patient's eyes and be asked to sit across the table, resting his head on the microscope attached to a slit lamp. Then the doctor will analyze the layers of the eyes through a lens. Any injury or increased eye pressure can be studied.

• Gonioscopy: This test is used to evaluate the drainage angle of the eyes. The space between the cornea and iris is studied where the trabecular meshwork is present. Gonioscopy is carried out with goniolens attached to a slit lamp.

• Hemoglobin Electrophoresis: It is the most commonly used test for confirming the presence of sickle cell anemia.

How to Treat Hyphema?

1) Conservative Treatment:

Trouble-free hyphema can be treated conservatively in the outpatient clinic itself. Doctors will advise the patient to wear an eye shield, limit the eye movements and keep the head elevated at 45° to maintain blood in the inferior part of the anterior chamber. These patients should be closely followed for the next two to three days as the chances of increased bleeding is high.

2) Medical Management:

• Increased ocular pressure is one of the main concerns with hyphema. Doctors will first try to control increasing ocular pressure by topical application of aqueous suppressants like beta-blockers and alpha agonists and then systemic acetazolamide or mannitol if the topical application does not work. Even after topical and systemic medications are given, if the intraocular pressure does not normalize, then surgical intervention is required.

• Topical corticosteroids reduce inflammation in severe cases, even though corticosteroids increase the risk of rebleeding (debatable).

• NSAIDs are strictly avoided in pain control as they can increase bleeding.

• Hypersomatic drugs are prescribed in patients to decrease sickle cell activity.

3) Surgical Intervention:

In most hyphema cases, medical management is more than enough for it to resolve. Only 5% of traumatic hyphema require surgery. The patient will be monitored for four days to determine the condition, and surgical intervention is advised if the situation doesn't settle.

The surgical steps involved are,

• Irrigation of the anterior chamber.

• Aspiration of the contents through a small incision.

• Trabeculectomy (creating a new pathway for the fluid to drain).

• At times, anterior chamber paracentesis (fluid removal) will also be done to control the elevated intraocular pressure.

• If it's a total hyphema where the pupil will be blocked entirely, a peripheral iridotomy procedure (a small incision is made in the iris to drain the aqueous humor into the anterior chamber, thereby relieving the pupillary block) is done.

What Complications Can Occur After Hyphema Surgery?

• Rebleeding.

• Corneal blood staining.

• Trabecular meshwork obstruction.

• Pupillary block.

• Damage to the optic nerve.

Prognosis:

Prognosis solely depends on the cause of the condition. Post-surgical follow-up of the patient is very critical in determining success.

Conclusion

Hyphema can happen to anybody at any time. Even if we get hurt, the flourishing medical technologies make it easy for us to handle the situation. It is always safe to wear protective shields while in the field, prone to accidents.