What is the initial treatment approach for a patient with a 20% hyphema?

Management of 20% Hyphema

The initial treatment for a 20% hyphema should include bed rest with head elevation, topical cycloplegics, topical corticosteroids, systemic antifibrinolytic agents, and a rigid eye shield, along with careful monitoring of intraocular pressure. 1

Initial Management

• Apply a rigid eye shield to protect the eye from further trauma 1
• Prescribe topical cycloplegics (such as atropine 1%) to reduce pain and prevent synechiae formation 1
• Administer topical corticosteroids to reduce inflammation 1
• Consider systemic antifibrinolytic agents (aminocaproic acid or tranexamic acid) to reduce the risk of rebleeding 1
• Restrict activity to quiet ambulation; complete bed rest is not necessary for small to moderate hyphemas 2
• Position the patient with head elevated 20-30 degrees to allow blood to settle inferiorly 3
• Avoid non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet medications 1

Monitoring and Follow-up

• Monitor intraocular pressure (IOP) frequently, as elevated IOP is a common complication 1, 4
• Schedule daily follow-up examinations for the first 3-5 days to monitor for rebleeding, which typically occurs within 2-5 days after initial injury 1
• Assess visual acuity at each visit, maintaining consistent testing methods 4
• Perform slit lamp examination to evaluate hyphema size and corneal clarity 4

Management of Complications

• For elevated IOP, initiate topical beta-blockers, alpha-2 agonists, or carbonic anhydrase inhibitors 1
• Avoid prostaglandin analogs as they may increase inflammation 1
• For significant IOP elevation (>30 mmHg) unresponsive to topical therapy, consider oral or intravenous medications 1
• Monitor for corneal blood staining, which is more likely with large hyphemas (>50%) and elevated IOP 1, 5

Special Considerations

• Patients with sickle cell disease or trait require more aggressive management due to higher risk of complications 1, 5
• Children may require hospitalization to ensure compliance with treatment and activity restrictions 4
• Outpatient management is appropriate for most patients with small to moderate hyphemas if there are no concerns about compliance, follow-up, or increased risk for complications 1

Surgical Intervention

• Consider surgical evacuation of the hyphema if:
  • Corneal blood staining develops 1
  • IOP remains dangerously elevated despite maximum medical therapy 1
  • The hyphema fails to clear after 9-10 days 5
  • Total hyphema (100% fill) persists for more than 5 days 5

Prognosis

• Most small to moderate hyphemas resolve with conservative management within 5-7 days 3
• The risk of rebleeding ranges from 0-38%, with higher risk in patients of African descent 1
• Visual prognosis is generally good with appropriate management, though depends on the severity of associated ocular injuries 1, 3

The management approach should be tailored based on hyphema size, IOP, and patient-specific risk factors. While the evidence suggests that strict bed rest does not improve outcomes for small hyphemas 2, activity restriction remains an important component of management to reduce the risk of rebleeding.