Hyphema (quick review)

13 Dec

hyphema1Hyphema = Blood in the anterior chamber

What causes this? Stretching of the ciliary body or iris during trauma, causing vessels to leak in to the anterior chamber  

Signs/sx: Photophobia, pain, decreased visual acuity, elevated IOP, corneal blood staining (blood layering out in the anterior chamber)  

Grading system:  


 What to do in the ED:

  1. Look for other injuries- obviously ABC’s, intracranial trauma, orbital fractures, globe rupture, retina/vitreous detachment, lens trauma…
  2. Again, make sure there is not an open globe or increased IOP.
  3. Pain control- tetracaine drops +/- cycloplegics (such as cyclopentolate or scopolamine 0.25%- 1 drop).  Do not use either if there is a globe rupture.
  4. Rigid eye shield
  5. Increase HOB to 30 degrees
  6. Certainly an ophthalmology consult.  As discussed below, if the patient is high risk, this is an urgent ophtho consult.
  7. In a patient with a spontaneous hyphema or very trivial injury, consider evaluation for clotting disorder, eye tumor, child abuse, other systemic disease.


High risk features:

  1. Blood filling >1/3 of eye
  2. Sickle cell disease
  3. High initial IOP (>22)
  4. Young child
  5. Anticoagulation or clotting disorder



  1. Increased IOP (blood in anterior chamber clogging trabeculae causing traumatic glaucoma)- can result in permanent vision loss
  2. Rebleeding (2-5 days later)- can result in permanent vision loss
  3. Peripheral anterior synechiae (iris adheres to cornea)
  4. Optic atrophy
  5. Corneal bloodstaining



  1. If high risk- admit patient
  2. If low risk- home with very close f/u
  • a)      Daily ophthalmology checks (for IOP checks)
  • b)      Limited activity-resting at home
  • c)       HOB up to at least 30 degrees
  • d)      Rigid eye shield x1 week
  • e)      Pain control and sometimes other treatments per ophthalmology (steroids, tranexamic acid…)    


Submitted by H. Groth.


Sources: Romano PE et al. “Traumatic hyphema: a comprehensive review of the past half century yields 8076 cases for which specific medical treatment reduces rebleeding 62%, from 13% to 5%”. Binoc Vis Strabismus Q. 2000;15(2):175.; Up-to-date; Walton, W et al. “Management of traumatic hyphema” Surv Opthalmol. 2002; 47(4):297.  


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