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Hyphema (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

Hyphema

14 y/o with blurry vision, unequal pupils, and injected conjunctiva/sclera

Patient will present as → a 14-year-old who sustained a blunt trauma to his right eye after being struck by a baseball. He complains of blurry vision. On physical exam, you note unequal pupils, injected conjunctiva/sclera, and blood in the anterior chamber of the right eye.

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Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris). The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye.

  • The mechanism of injury varies by age ⇒ usually from blunt/penetrating trauma
    • Young children: baseball, softball, soccer, hockey, racquetball, etc.
    • Teenagers and adults: assault, paintballs, airbags, bungee cords, etc.
  • In trauma ⇒ bleeding results from tears in the vessels of the ciliary body or iris
  • In penetrating injury ⇒ bleeding results from direct damage to the iris
  • If there is trauma you need to make sure there is no other type of injury – skull fracture, orbital fracture, etc., etc.
Hyphema - occupying half of anterior chamber of eye

Hyphema with blood in the anterior chamber

Traumatic hyphema is a clinical diagnosis that is made based upon a history of eye trauma and characteristic findings during an ophthalmologic examination

  • Orbital CT in patients with a suspected open globe or concern for serious orbital injury
  • All patients with a traumatic hyphema warrant prompt evaluation by an ophthalmologist to provide expertise in comprehensive eye examination, including intraocular pressure measurement.

All patients with a traumatic hyphema warrant prompt evaluation by an ophthalmologist to provide expertise in comprehensive eye examination, including intraocular pressure measurement.

  • Frequently, blood is reabsorbed over a period of days to weeks
  • Eyeshield - To avoid further injury to the affected eye, an eye shield should be worn at all times until the hyphema resolves or for at least one week 
  • Elevate the head of the bed at 30 degrees all the time
  • Patients with traumatic hyphema receive topical glucocorticoid eye drops
  • Daily monitoring of intraocular pressure is a cornerstone in the management of traumatic hyphema
    • A normal intraocular pressure (IOP) generally falls within the range of 10-21 mmHg (millimeters of mercury)
  • NSAIDs are contraindicated as they may lead to increased bleeding into the anterior chamber
  • Surgery if high pressure or persistent bleeding

Question 1
A patient presents with a traumatic hyphema following a blunt injury to the eye. Which of the following is a recognized potential complication associated with this condition?
A
Retinal detachment
Hint:
While retinal detachment can occur due to trauma, it is not a direct complication of hyphema itself.
B
Secondary glaucoma
C
Cataract formation
Hint:
Cataracts typically develop due to lens changes, which are not directly associated with hyphema.
D
Chronic conjunctivitis
Hint:
Conjunctivitis is an inflammation of the conjunctiva and is not a typical complication of hyphema.
E
Corneal scarring
Hint:
While corneal injury can occur with ocular trauma, corneal scarring is not a direct complication of hyphema.
Question 1 Explanation: 
Secondary glaucoma is a well-recognized complication of traumatic hyphema. The accumulation of blood in the anterior chamber of the eye can obstruct the trabecular meshwork, leading to increased intraocular pressure. If not promptly and effectively managed, this can result in glaucomatous damage to the optic nerve and potential vision loss.
Question 2
A 20-year-old woman presents with decreased vision and eye pain after a motor vehicle accident. On slit-lamp examination, a homogenous blood layer is noted in the anterior chamber of her right eye. What is the most important factor to assess next in the management of this patient?
A
Measurement of intraocular pressure
B
Fundoscopic examination
Hint:
Important for assessing the retina but secondary to intraocular pressure measurement in acute hyphema.
C
CT scan of the orbit
Hint:
Useful in assessing for orbital fractures but not the immediate concern in isolated hyphema.
D
Fluorescein staining of the cornea
Hint:
Used to detect corneal abrasions, not directly relevant in hyphema.
E
Visual acuity test
Hint:
Important but secondary to intraocular pressure measurement in this context.
Question 2 Explanation: 
Measurement of intraocular pressure is crucial in the management of hyphema, as elevated pressure can indicate secondary complications like angle-recession glaucoma. Timely identification and management of increased intraocular pressure are essential to prevent further damage to the eye.
Question 3
A 15-year-old boy is diagnosed with a small hyphema following a basketball injury. He has no history of sickle cell disease, and his intraocular pressure is normal. What is the most appropriate initial management for this patient?
A
Immediate surgical evacuation of the hyphema
Hint:
Indicated in cases with high intraocular pressure or sickle cell disease.
B
Patching both eyes
Hint:
Not recommended as it can increase the risk of amblyopia in children.
C
Topical corticosteroids
Hint:
May be used to reduce inflammation but are not the primary treatment.
D
Antifibrinolytic therapy
Hint:
Used in cases with a high risk of re-bleeding.
E
Bed rest with head elevation
Question 3 Explanation: 
For a small hyphema with normal intraocular pressure and no sickle cell disease, the most appropriate initial management is bed rest with head elevation. This position helps settle the blood and reduces the risk of re-bleeding.
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References: Merck Manual · UpToDate

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