Ophthalmic Trauma

Michael Rubin, MD
Department of Ophthalmology and
Visual Science
The University of Chicago
 Presentation
15 y/o AAM presents to the Peds ED
Boy states the he got hit by a friend in the
eye last night
Initial Presentation
 What Questions would you ask this patient?
 How would you examine this patient?
 What tests would you order?
 How would you treat this patient?
 What other problems are you worried
about?
 What causes a hyphema
The agent producing a hyphema is usually a
projectile that strikes the the eye.
Various objects have been incriminated,
including balls, rocks, projectile toys, air gun
pellets, BB gun pellets, and the human fist.
With the increase of child abuse, fists and
belts have started to play a prominent role.
Males are involved in three fourths of cases
 Spontaneous Hyphema
Spontaneous hyphemas are secondary
to neovascularization (eg, diabetes
mellitus, ischemia, cicatrix formation),
ocular neoplasms (eg, retinoblastoma),
and vascular anomalies (eg, juvenile
xanthogranuloma).
 Grading a Hyphema
The following clinical grading system for
traumatic hyphemas is preferred:
Grade 1 - Layered blood occupying less than
one third of the anterior chamber
Grade 2 - Blood filling one third to one half of the
anterior chamber
Grade 3 - Layered blood filling one half to less
than total of the anterior chamber
Grade 4 - Total clotted blood, often referred to as
blackball or 8-ball hyphema
 Grouping
58% involve less than one third of the anterior
chamber
20% involve one third to one half of the
anterior chamber
14% involve one half to less than total of the
anterior chamber
8% are total hyphemas.
50% of all hyphemas settle inferiorly to form a
level
 Mechanism
Sudden dynamic shift stretches the limbal
vessels and displaces the iris and the lens.
This displacement may result in a tear at the
iris or the ciliary body, usually at the angle
structures.
The blood exits from the anterior chamber via
the trabecular meshwork and the Schlemm
canal or the juxtacanalicular tissue.
 Course
The usual duration of an uncomplicated
hyphema is 5-6 days. The mean
duration of elevated intraocular
pressure is 6 days.
 Increased IOP
Elevated intraocular pressures (>22 mm
Hg) may be anticipated in approximately
32% of all patients with hyphemas.
Higher, more prolonged elevations of
intraocular pressure are more commonly
associated with near total or total
hyphemas.
 Delayed Glaucoma
Ghost cell glaucoma with hyphema and
vitreous hemorrhage may cause elevated
intraocular pressure 2 weeks to 3 months
after the initial injury
Gradual clearing of the hyphema occurs, with
erythrocytes losing hemoglobin in the vitreous
cavity. The ghost cells then circulate forward
into the anterior chamber, with resultant
trabecular blockage.
 Secondary Bleeding
Secondary bleeding into the anterior chamber
results in a markedly worse prognosis.
Eventual visual recovery to a visual acuity of 20/50
or better occurs in approximately 64% of patients
with secondary hemorrhage as compared with
79.5% of patients in whom no rebleeding occurred.
Secondary hemorrhage occurs in approximately
25% (range, 7-38%) of all patients with hyphema.
The incidence of secondary hemorrhage is higher
in hyphemas classified as Grades 3 and 4
 Race Influence
Several studies have documented that
secondary hemorrhage occurs more
frequently in black patients.
In 1990, Spoor et al observed
secondary hemorrhage in 24.2% of
black patients and in only 4.5% of
Caucasian patients.
 Complications of Hyphema
Complications of traumatic hyphema
may be directly attributed to the
retention of blood in the anterior
chamber.
The four most significant complications
include posterior synechiae, peripheral
anterior synechiae, corneal
bloodstaining, and optic atrophy.
Corneal Blood Staining
Optic Atrophy
Commotio Retinae
Pre-retinal Heme
Retinal Detachment
 Determinants of Prognosis
1. Amount of associated damage to other
ocular structures (ie, choroidal rupture,
macular scarring)
2. Whether secondary hemorrhage occurs
3. Whether complications of glaucoma,
corneal bloodstaining, or optic atrophy
occur
 Prognosis
The success of hyphema treatment, as judged
by the recovery of visual acuity, is good in
approximately 75% of patients.
Approximately 80% of those with less than
one third filling of the anterior chamber regain
visual acuity of 20/40 (6/12) or better.
Approximately 60% of those with a hyphema
occupying greater than one half but less than
total of the anterior chamber regain visual
acuity of 20/40 (6/12) or better.
 Modifying Factors
35% of those with an initially total
hyphema or a Grade 4 hyphema have
good visual results.
60% of patients younger than 6 years
have good visual results.
 Treatment
The customary treatment of patients
with traumatic hyphema has included
hospitalization, bed rest, bilateral
patching, and sedation.
 Need to Hospitalize
No statistically significant difference
exists in most areas of comparison
between patients treated with bed rest,
bilateral patches, and sedation and
those treated with ambulation, a patch
and shield on the injured eye only, and
no sedation
 Pain Control
If analgesics are required for pain relief,
acetaminophen (Tylenol) with or without
codeine, depending on the severity of the pain,
is preferred.
The antiplatelet effect of aspirin tends to
increase the incidence of rebleeding in patients
with traumatic hyphema and should be strictly
avoided.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
share this deleterious antiplatelet effect.
 Other therapeutic measures
The injured globe requires adequate protection
with a patch and shield.
Elevating the head of the bed 30-45 facilitates
settling of the hyphema in the inferior anterior
chamber and aids in classifying the hyphema.
Inferior settling facilitates more rapid
improvement of visual acuity, earlier evaluation
of the posterior pole, and greater clearing of
the anterior chamber angle.
 Steroids and Cycloplegics
Steroids after the third day or the fourth day
of retained hyphema may be advantageous
to decrease the associated iridocyclitis and to
prevent or deter the development of
peripheral anterior synechiae or posterior
synechiae.
Atropine (1%) is indicated in hyphemas
occupying more than 50% of the anterior
chamber to break the pupillary block.
 AMICAR
Several double-masked studies clearly establish
the value of systemic aminocaproic acid (ACA,
AMICAR) in the prevention of recurrent
hemorrhages.
ACA retards clot lysis by preventing plasmin from
binding to the lysine in the fibrin clot. As a lysine
analog, ACA competitively inactivates plasmin by
occupying the site on plasmin that would normally
bind to fibrin. In a similar manner, ACA binds to
plasminogen, so that when activated to plasmin, it
cannot attach to fibrin.
 ACA
In a prospective study by the authors, as well
as 2 additional studies, patient groups treated
with ACA and placebo were randomized and
double-masked (Crouch, 1976; Palmer, 1986;
McGetrick, 1983; Kutner, 1987). In the ACA-
treated group, the incidence of secondary
hemorrhage varied 3-4% (Crouch, 1976;
Palmer, 1986; McGetrick, 1983; Kutner,
1987). In the placebo-treated group, the
incidence was 28-33%.
 Topical ACA
Topical ACA appears to be a safe, effective
treatment to prevent secondary hemorrhage
in patients with traumatic hyphema. It is as
effective as systemic ACA in reducing
secondary hemorrhage, and no systemic
adverse effects were observed with topical
use. Topical ACA provides an effective
outpatient treatment for traumatic hyphemas.
 Outpatient Treatment
Microhyphemas can be treated on an
outpatient basis, unless secondary
hemorrhage occurs or elevated intraocular
pressure is uncontrolled.
Patients with traumatic hyphema occupying
less than one third of the anterior chamber
can be treated on an outpatient basis with
systemic or topical ACA.
 Hospitalization
If the hyphema occupies more than one
third of the anterior chamber, intraocular
pressure is elevated beyond 30 mm Hg,
or both, hospitalization is
recommended.
 Indication for Surgery
Four days after onset of total hyphema
Microscopic corneal bloodstaining
Total hyphema with intraocular
pressures of 50 mm Hg or more for 4
days Total hyphemas or hyphemas
filling greater than 75% of the anterior
chamber present for 6 days with
pressures of 25 mm Hg or more
 More surgical indications
Hyphemas filling greater than 50% of
the anterior chamber retained longer
than 8-9 days
In patients with sickle cell trait or sickle
cell disease who have hyphemas of any
size that are associated with intraocular
pressures of greater than 35 mm Hg for
more than 24 hours
 Sickle Cell
Patients with sickle cell
hemoglobinopathies and even those
with sickle cell trait require surgical
intervention if intraocular pressure is not
controlled within 24 hours