From the Research
Management of hyphema in emergency requires prompt attention to prevent complications like increased intraocular pressure and corneal blood staining, with the most recent and highest quality study suggesting that systemic aminocaproic acid or tranexamic acid may reduce the rate of secondary hemorrhage, although the evidence is of low certainty 1.
Initial Management
Initial management includes placing the patient at 30-45 degrees head elevation to allow blood to settle inferiorly. Activity restriction and eye protection with a shield are essential to prevent rebleeding.
- Cycloplegic drops such as cyclopentolate 1% or atropine 1% three times daily help reduce pain and prevent synechiae formation.
- For pain control, acetaminophen is preferred; NSAIDs and aspirin should be avoided due to bleeding risk.
Monitoring and Medical Therapy
Intraocular pressure should be monitored, and if elevated, topical beta-blockers like timolol 0.5% twice daily, alpha-2 agonists like brimonidine 0.2% three times daily, or carbonic anhydrase inhibitors like dorzolamide 2% three times daily can be used.
- In severe cases with pressure >30 mmHg, oral acetazolamide 250-500 mg four times daily may be necessary.
- Patients with sickle cell trait or disease require more aggressive pressure management to prevent sickling in the anterior chamber.
Follow-up and Surgical Intervention
Daily follow-up is needed until the hyphema resolves, typically within 5-7 days.
- Surgical intervention with anterior chamber washout is indicated for hyphemas that persist beyond 7-10 days, cause persistent elevated pressure despite medical therapy, or result in corneal blood staining. The use of antifibrinolytic agents, such as aminocaproic acid or tranexamic acid, may be considered to reduce the rate of secondary hemorrhage, although the evidence is limited and of low certainty 1, 2. However, the most recent study 1 provides the best evidence for guiding management decisions, and its findings should be prioritized in clinical practice.