H21.01-03 Hyphema of Iris and Ciliary Body

Hyphema is a condition where blood from the iris or ciliary body hemorrhages into the anterior chamber.  A hyphema may appear as a few red blood cells or it can completely fill the anterior chamber.

1.  Traumatic hyphema is usually a result of blunt force injury to the eye or orbit.  In addition to the original hemorrhage, a secondary hemorrhage can occur at an time up to one week after the original injury.

2.  Iatrogenic hyphema can occur intraoperatively during a surgical procedure or at any time postoperatively.

3.  Non-traumatic hyphema can occurs spontaneously if it is associated with the following conditions:

• Neovascularization of the iris
• Neovascularization in the anterior chamber angle
• Iris lesions
• Malpositioned/loose intraocular lens

Structural Damage to the Eye

1.  Blood in the trabecular meshwork can result in slowed aqueous drainage

2.  Obstruction to aqueous outflow can produce a secondary glaucoma

3.  Methods of hyphema formation during intraocular surgery include the following:

• Intraoperative bleeding — ciliary body or iris gets injured during a peripheral iridectomy, cataract extraction, cyclodialysis, or filtration procedure
• Early postoperative bleeding — a traumatized uveal blood vessel in spasm earlier and suddenly dilates or conjunctival bleeding that makes its way into the anterior chamber via a corneoscleral wound or sclerostomy
• Late postoperative bleeding — new blood vessels growing across the corneoscleral wound that bleed when manipulated; a uveal wound that is reopened; an intraocular lens that is causing chronic iris erosion

Functional Damage to the Eye

• Transient vision loss
• Permanent vision loss secondary to corneal blood staining
• Permanent vision loss secondary to glaucoma

The main goal of the diagnostic evaluation in a patient with hyphema is to accomplish the following:

• Identify the cause of the hyphema
• Evaluate any structural damage to the orbit and the eye
• Identify and exclude differential diagnoses
• Prescribe a treatment program

The patient history, a general medication observation, an examination of the gross visual fields, a basic sensorimotor examination, the adnexal examination, the external examination with biomicroscopy and ophthalmoscopy will be necessary to gain all the information required to make a clinical diagnosis of hyphema and its potential complicatons.

Patient History

Patients with hyphema may present with any of the following abnormal clinical signs and symptoms:

• Recent history of trauma
• Pain
• Blurred vision
• Swelling of the lids
• Foreign body sensation
• Redness of the eye
• Transient blurred vision
• Loss of vision
• Double vision 

Adnexal Examination

Trauma to the adnexa will have all the signs and symptoms associated with blunt trauma to the eyelids or the orbit.  To rule out orbital fracture or extraocular muscle entrapment, X-ray or CT scan may be necessary.

Ophthalmoscopic Examination

In cases of blunt ocular trauma, a dilated fundus examination without scleral depression is needed to rule out retinal detachment or other contusion damage to the retina.

DIAGNOSTIC TESTS

External Ocular Photography

The clinical application of external ocular photography is the documentation, monitoring and treatment of any pathological conditions that affect the external structures of the eye and the anterior segment of the eye.

• Document the location and extent of the hyphema.
• Document any other associated structural changes to the cornea and the eyelids.
• Help plan a treatment program for hyphema.

The information provided by external ocular photography is used for medical decision-making in the following manner:

• To document the progress or lack of progress of the hyphema
• To document the delivery of medical treatment
• To document the response to treatment

Gonioscopy

The clinical application of gonioscopy is the documentation, monitoring and treatment of any pathological conditions that affect the anterior segment of the eye.

• Document the location and the extent of the hyphema
• Document any structural changes to the iris or the anterior chamber angle of the eye
• Document any obstruction to aquesous outflow secondary to the hyphema
• Help plan a treatment program for hyphema

The information provided by gonioscopy is used for medical decision-making in the following manner:

• To document the progress or lack of progress of the hyphema
• To assess the risk of developing secondary glaucoma
• To document the delivery of medical treatment
• To document the response to treatment

B-Scan Ophthalmic Ultrasound

The clinical application of B-scan ophthalmic ultrasound is the documentation, monitoring and treatment of any pathological conditions that affect the external structures of the eye, the anterior segment of the eye or the posterior segment of the eye.  B-scan is used when the hyphema or a vitreous hemorrhage prevents the proper visualization and examination of the retina.

• Document the status of the retina after  blunt ocular trauma
• Document any other associated structural changes to the eye, extraocular muscles or the orbit
• Identify and exclude other causes of the hyphema such as intraocular foreign body or intraocular tumor
• Help plan a treatment program for the hyphema

Information provided by the B-scan ophthalmic ultrasound is used for medical decision-making in the following manner:

• To document the level of structural damage to the eye following blunt ocular trauma
• To assist in identifying and excluding differential diagnoses
• To document the delivery of medical treatment
• To document the response to treatment

There are two broad ways to classify blood in the anterior chamber — microhyphema and hyphema.  Microhyphema is suspended red blood cells in the anterior chamber seen with a slit-lamp examination.  Hyphema is a layer or clot of blood easily seen without a slit-lamp examination.

In addition, the Hyphema Clinical Grading System classifies hyphemas by the height of the blood in the anterior chamber.

Sickle Cell Traits/Disease

African-American and Mediterranean patients should be screened for systemic disease if a spontaneous hyphema is diagnosed. 

Juvenile Xanthogramuloma

A dermalogical disorder primarily in infants and children can have manifestations of recurrent, spontaneous hyphemas due to uveal tract involvement.

Retinoblastoma

Microhyphemas may be present due to the intraocular tumor.

Most clinicians can manage patients with hyphema with one or more of the following treatment options:

Palliative Treatment

1.  Sheppard J.  Hyphema.  Medscape/EMedicine.  http://emedicine.medscape.com/article/1190165-overview.  Last accessed August 16, 2014.
2.  Hyphema.  Handbook of Ocular Disease Management. http://www.reviewofoptometry.com/cmsdocuments/2012/6/ro0612_hndbk_em.pdf.  Last accessed August 16, 2014.