What is the appropriate management for hyphema (blood in the anterior chamber of the eye) resulting from a traumatic fall?

Management of Traumatic Hyphema

Traumatic hyphema (blood in the anterior chamber of the eye) resulting from a fall requires prompt ophthalmologic evaluation and specific management to prevent vision-threatening complications such as increased intraocular pressure, corneal blood staining, and optic nerve damage.

Initial Assessment

• Assess visual acuity, intraocular pressure, and extent of bleeding
• Evaluate for associated injuries (lens dislocation, retinal damage, orbital fractures)
• Classify hyphema by grade:
  • Grade 1: <1/3 of anterior chamber
  • Grade 2: 1/3 to 1/2 of anterior chamber
  • Grade 3: 1/2 to total filling with visible blood level
  • Grade 4: Total filling ("eight-ball" or "blackball" hyphema)

Medical Management

1. Activity Restriction

   • Elevate head of bed 30-45 degrees to allow blood to settle
   • Limited activity with no heavy lifting or straining
   • Avoid antiplatelet medications and NSAIDs

2. Eye Protection

   • Shield or protective glasses during day
   • Eye shield at night to prevent accidental trauma

3. Medications

   • Antifibrinolytic agents: Consider tranexamic acid (10-15 mg/kg followed by 1-5 mg/kg/h infusion) to reduce risk of rebleeding 1
   • Cycloplegics (e.g., atropine) to reduce pain and prevent synechiae formation
   • IOP-lowering medications if pressure elevated (topical beta-blockers, alpha-agonists, or carbonic anhydrase inhibitors)
   • Avoid prostaglandin analogs which may promote inflammation

4. Monitoring

   • Daily intraocular pressure measurements
   • Regular slit lamp examinations to monitor resolution
   • Watch for signs of rebleeding (occurs in 20-33% of cases, most commonly 2-5 days after injury)

Special Considerations

• Sickle cell disease/trait: Patients require more aggressive management as they are at higher risk for complications from elevated IOP
• Elevated IOP: If >24 mmHg, immediate treatment is required to prevent optic nerve damage
• Corneal blood staining: Can occur with prolonged hyphema, especially with elevated IOP

Surgical Intervention

Surgical evacuation of hyphema is indicated for:

• IOP >50 mmHg for >24 hours despite maximum medical therapy
• IOP >35 mmHg for >7 days
• Corneal blood staining
• Total hyphema persisting >5-7 days
• Early signs of corneal blood staining

Complications to Monitor

• Secondary hemorrhage (rebleeding)
• Increased intraocular pressure and secondary glaucoma
• Corneal blood staining
• Peripheral anterior synechiae
• Optic atrophy

Evidence-Based Outcomes

The Cochrane review on traumatic hyphema management found that while antifibrinolytic agents (aminocaproic acid and tranexamic acid) reduced the rate of secondary hemorrhage, there was no clear evidence of effect on final visual acuity 1. The review found limited evidence supporting the use of corticosteroids, cycloplegics, or non-drug interventions like patching or bed rest.

Follow-up

• Daily follow-up initially until stabilized
• Then every 2-3 days until resolution
• Weekly follow-up for 3-4 weeks after resolution
• Monitor for late complications including glaucoma and cataract formation

Early and appropriate management of traumatic hyphema is crucial to prevent vision-threatening complications and preserve visual function.