What is the management for hyphema?

Management of Traumatic Hyphema

Initial Management Approach

For traumatic hyphema, initiate topical corticosteroids (prednisolone preferred) and cycloplegics immediately, protect the eye with a rigid shield, elevate the head, and allow quiet ambulation rather than strict bed rest, as bed rest does not improve outcomes for small hyphemas. 1, 2, 3

Immediate Medical Therapy

• Topical corticosteroids should be started routinely, with prednisolone being the preferred agent (used by 88.9% of institutions worldwide) 2
• Topical cycloplegics are indicated in nearly all cases to reduce pain and prevent synechiae formation 1, 2, 4
• Rigid eye shield (not patch) should be applied to protect against further trauma 1
• Avoid NSAIDs and aspirin completely, as these antiplatelet agents increase rebleeding risk 1, 4

Activity and Positioning

• Head elevation is the most effective intervention to promote hyphema reabsorption (used by 86.3% of institutions) 2
• Quiet ambulation is acceptable and does not worsen outcomes compared to strict bed rest, even for small hyphemas occupying less than one-third of the anterior chamber 3
• Strict bed rest does not reduce the 15% overall rebleed rate and provides no statistical benefit 3

Inpatient vs Outpatient Management

Outpatient management is appropriate if the patient is compliant, has reliable follow-up, and lacks high-risk features (sickle cell disease, hemophilia, large hyphema >50% anterior chamber volume) 1

• 69.4% of institutions do not routinely admit hyphema patients 2
• 75% of institutions schedule follow-up within 48 hours of presentation 2
• Hospitalization is reserved for: non-compliant patients, children at risk for reinjury, patients with sickle cell trait/disease, those with large hyphemas, or patients with uncontrolled intraocular pressure 1, 4

Monitoring for Complications

Rebleeding Risk

• Secondary hemorrhage occurs in 0-38% of cases, typically 3-5 days post-injury 1, 4
• Higher risk groups include: African-Americans, children, patients with sickle cell disease, and those who ingested aspirin or antiplatelet agents 1, 4
• Rebleeding conveys worse visual prognosis primarily due to larger hyphema size and associated injuries rather than the rebleed itself 1

Intraocular Pressure Management

• Monitor IOP closely as elevated pressure is a major complication requiring medical therapy 1, 4, 5
• Use standard antiglaucoma medications if IOP elevation occurs 1, 4
• Avoid carbonic anhydrase inhibitors in patients with sickle cell disease, as acidosis promotes sickling 1

Corneal Blood Staining

• Occurs with prolonged hyphema and elevated IOP 1, 4
• Represents an indication for surgical intervention if developing 1

Special Populations

Sickle Cell Disease/Trait

• Only 16.7% of institutions routinely perform sickle cell testing, though this population requires heightened vigilance 2
• These patients are at increased risk for rebleeding and complications from elevated IOP 1, 4
• Avoid medications that promote acidosis (carbonic anhydrase inhibitors) 1

Children

• Higher rebleed risk compared to adults 4
• Consider hospitalization more liberally due to compliance concerns and risk of reinjury 1, 5

Surgical Intervention Indications

Anterior chamber washout is indicated when: 1, 2

• Corneal blood staining is present or developing
• Intraocular pressure remains dangerously elevated despite maximum tolerated medical therapy
• Hyphema occupies >50% of anterior chamber for >5 days (some institutions use this threshold)
• Total hyphema persists for >9 days
• IOP >50 mmHg for >5 days or >35 mmHg for >7 days in patients with normal optic nerves

The decision to perform surgical washout varies significantly between institutions and should be individualized based on IOP response and speed of hyphema resolution 2

Controversial/Not Recommended Interventions

• Antifibrinolytic agents (aminocaproic acid, tranexamic acid) are not routinely used by any surveyed institution, despite historical advocacy 2
• Strict bed rest provides no benefit over quiet ambulation for small hyphemas 3
• Routine hospitalization is not necessary for uncomplicated cases with reliable follow-up 2

Follow-up Assessment

• Examine within 48 hours of initial presentation 2
• Assess for: visual acuity changes, IOP elevation, rebleeding, corneal clarity, and associated injuries (corneal edema, cataract, mydriasis, retinal damage) 4, 5
• Perform gonioscopy after hyphema resolution to assess for angle damage and synechiae 4
• Fundus examination is essential to identify posterior segment injuries 4

Common Pitfalls to Avoid

• Do not use NSAIDs or aspirin for pain control, as these increase rebleeding risk 1, 4
• Do not assume bed rest improves outcomes—it does not, and quiet ambulation is acceptable 3
• Do not overlook sickle cell screening in high-risk populations (African-Americans), as these patients require modified management 1, 4
• Do not delay surgical intervention when clear indications exist (corneal blood staining, refractory elevated IOP) 1