What medications are prescribed for hyphema?

Management of Hyphema

For hyphema treatment, topical cycloplegics and corticosteroids are the primary medications prescribed, along with activity restriction and eye protection. Based on the most recent evidence, this approach helps prevent complications such as increased intraocular pressure, corneal blood staining, and secondary hemorrhage.

First-Line Medications

Topical Cycloplegics

• Atropine 1% ophthalmic solution is commonly prescribed to:
  • Reduce pain from ciliary spasm
  • Stabilize the blood-aqueous barrier
  • Prevent formation of posterior synechiae
  • Typically administered 1-2 times daily 1

Topical Corticosteroids

• Prednisolone acetate 1% is the preferred steroid (used by 88.9% of institutions) 2
  • Reduces inflammation
  • Helps stabilize blood vessels
  • Prevents secondary hemorrhage
  • Typically administered 4-6 times daily
  • Gradually tapered as the hyphema resolves

Supportive Measures

Activity Restrictions

• Head elevation (30-45 degrees) to promote hyphema reabsorption 2
• Partial bed rest with quiet ambulation
• Avoidance of strenuous activity
• No eye rubbing

Eye Protection

• Rigid eye shield (not patch) to protect from additional trauma 1
• Should be worn continuously, especially during sleep

Follow-Up Care

• First follow-up within 24-48 hours of initial presentation 2
• Monitor for:
  • Intraocular pressure (IOP) elevation
  • Secondary hemorrhage (most common 3-5 days post-injury)
  • Corneal blood staining
  • Anterior or posterior synechiae formation

Special Considerations

Elevated Intraocular Pressure

• If IOP is elevated, consider:
  • Topical beta-blockers (timolol 0.5%)
  • Alpha-2 agonists (brimonidine)
  • Carbonic anhydrase inhibitors (dorzolamide or oral acetazolamide)
  • Avoid prostaglandin analogs as they may increase inflammation 1

Patients with Sickle Cell Disease/Trait

• Sickle cell testing should be considered, especially in African American patients 2
• Avoid carbonic anhydrase inhibitors and hyperosmotic agents in these patients
• Lower threshold for surgical intervention if IOP remains elevated

Pediatric Patients

• May require more aggressive management due to higher risk of rebleeding
• Consider hospitalization if compliance with medications or activity restrictions is a concern 1

Antifibrinolytic Agents

• Aminocaproic acid may be considered in high-risk cases to prevent rebleeding
• Not routinely used by most institutions (0% reported routine use) 2

Surgical Intervention

Indications for anterior chamber washout include:

• Corneal blood staining
• Persistently elevated IOP despite maximum medical therapy
• Total hyphema persisting beyond 5-7 days
• Significant visual impairment with no improvement 3

Common Pitfalls to Avoid

• Avoid non-steroidal anti-inflammatory drugs (NSAIDs) as they increase bleeding risk 1
• Don't use eye patches (use shields instead) as they prevent observation of the eye
• Don't delay follow-up beyond 24-48 hours, as rebleeding risk is highest 3-5 days post-injury
• Don't forget to assess for associated ocular injuries, which commonly accompany traumatic hyphema

Proper medication management and close follow-up are essential to prevent vision-threatening complications of hyphema, with the treatment approach tailored to the severity of the hyphema and patient-specific risk factors.