What is the treatment for chronic traumatic hyphema?

Treatment of Chronic Traumatic Hyphema

The treatment of chronic traumatic hyphema should focus on preventing secondary hemorrhage with antifibrinolytic agents like tranexamic acid, while providing topical corticosteroids and cycloplegics to reduce inflammation and prevent complications. 1, 2

Medical Management

First-line Treatments

• Apply topical cycloplegics to reduce pain and prevent synechiae formation 1
• Administer topical corticosteroids to decrease inflammation 1
• Consider systemic antifibrinolytic agents (tranexamic acid or aminocaproic acid) to reduce the risk of secondary hemorrhage, which has been shown to decrease rebleeding rates (RR 0.33,95% CI 0.21 to 0.53 for tranexamic acid) 2
• Apply a rigid shield to protect the eye from further trauma 1

Activity Restrictions

• Recommend quiet ambulation rather than strict bed rest, as studies show no significant difference in outcomes between ambulation and complete bed rest 2
• Avoid non-steroidal anti-inflammatory agents as they may increase bleeding risk 1

Monitoring and Follow-up

• Daily ophthalmological review is necessary during the acute illness to monitor for complications 3
• Monitor intraocular pressure regularly, as elevated pressure is a common complication 1, 2
• Apply ocular lubricants (e.g., nonpreserved hyaluronate or carmellose eye drops) every 2 hours to protect the corneal surface 3

Complications Management

Elevated Intraocular Pressure

• Administer topical pressure-lowering therapies if intraocular pressure is elevated 3
• Monitor closely for optic nerve damage, especially in patients with sickle cell trait/disease who are particularly susceptible to pressure-related complications 2

Corneal Blood Staining

• Surgical intervention is indicated if corneal blood staining occurs 1
• Early intervention may prevent permanent corneal damage 2

Rebleeding

• Rebleeding is associated with worse visual outcomes and increased complications 2
• Systemic tranexamic acid has shown significant effect in reducing secondary hemorrhage rates 2
• Note that hyphema may take longer to clear in patients treated with systemic aminocaproic acid 2

Surgical Management

Indications for Surgery

• Dangerously increased intraocular pressure despite maximum tolerated medical therapy 1
• Presence of corneal blood staining 1
• Significant anterior chamber clot that doesn't resolve with medical management 2

Timing of Intervention

• For most cases, waiting 4-6 months after the initial trauma is advised to ensure stability before surgical intervention for any residual strabismus or other complications 3
• However, immediate surgical intervention is indicated for uncontrolled intraocular pressure or corneal blood staining 1

Special Considerations

Patients with Sickle Cell Disease

• Patients with sickle cell trait/disease require more aggressive management due to higher risk of complications 2
• Lower threshold for surgical intervention may be appropriate in these patients 1

Outpatient vs. Inpatient Management

• Outpatient management can be offered if there are no concerns regarding compliance with medications or activity restrictions 1
• Consider inpatient management for patients with sickle cell disease, hemophilia, or other bleeding disorders 1

Treatment Efficacy and Evidence

• No intervention has shown a significant effect on visual acuity outcomes, whether measured at two weeks or at longer time periods 2
• The evidence supporting reduction in risk of complications from secondary hemorrhage by antifibrinolytics is limited by the small number of events in studies 2
• Aminocaproic acid use is associated with increased nausea, vomiting, and other adverse events compared to placebo 2
• There is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions in improving visual outcomes, though they remain standard practice for symptom management 2