Hyphema is a condition that occurs when blood enters the front (

anterior Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...

) chamber of the eye between the

iris Iris most often refers to: *Iris (anatomy), part of the eye *Iris (mythology), a Greek goddess * ''Iris'' (plant), a genus of flowering plants * Iris (color), an ambiguous color term Iris or IRIS may also refer to: Arts and media Fictional ent ...

and the

cornea The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power ...

. People usually first notice a loss of vision or decrease in vision. The eye may also appear to have a reddish tinge, or it may appear as a small pool of blood at the bottom of the iris or in the cornea. A traumatic hyphema is caused by a hit to the eye from a projected object or a blow to the eye. A hyphema can also occur spontaneously.

Presentation

A decrease in vision or a loss of vision is often the first sign of a hyphema. People with microhyphema may have slightly blurred or normal vision. A person with a full hyphema may not be able to see at all (complete loss of vision). The person's vision may improve over time as the blood moves by gravity lower in the anterior chamber of the eye, between the iris and the cornea. In many people, the vision will improve, however some people may have other injuries related to trauma to the eye or complications related to the hyphema. A microhyphema, where red blood cells are hanging in the anterior chamber of the eye, is less severe. A layered hyphema when fresh blood is seen lower in the anterior chamber is moderately severe. A full hyphema (total hyphema), when blood fills up the chamber completely, is the most severe.

Complications

While the vast majority of hyphemas resolve on their own without issue, sometimes complications occur. Traumatic hyphema may lead to increased

intraocular pressure Intraocular pressure (IOP) is the fluid pressure inside the eye. Tonometry is the method eye care professionals use to determine this. IOP is an important aspect in the evaluation of patients at risk of glaucoma. Most tonometers are calibrated to ...

(IOP), peripheral anterior synechiae,

atrophy Atrophy is the partial or complete wasting away of a part of the body. Causes of atrophy include mutations (which can destroy the gene to build up the organ), poor nourishment, poor circulation, loss of hormonal support, loss of nerve supply t ...

of the

optic nerve In neuroanatomy, the optic nerve, also known as the second cranial nerve, cranial nerve II, or simply CN II, is a paired cranial nerve that transmits visual system, visual information from the retina to the brain. In humans, the optic nerve i ...

, staining of the cornea with blood, re-bleeding, and impaired accommodation. Secondary hemorrhage, or rebleeding of the hyphema, is thought to worsen outcomes in terms of visual function and lead to complications such as

glaucoma Glaucoma is a group of eye diseases that result in damage to the optic nerve (or retina) and cause vision loss. The most common type is open-angle (wide angle, chronic simple) glaucoma, in which the drainage angle for fluid within the eye rem ...

, corneal staining,

optic atrophy Optic neuropathy is damage to the optic nerve from any cause. The optic nerve is a bundle of millions of fibers in the retina that sends visual signals to the brain. Damage and death of these nerve cells, or neurons, leads to characteristic featu ...

, or

vision loss Visual impairment, also known as vision impairment, is a medical definition primarily measured based on an individual's better eye visual acuity; in the absence of treatment such as correctable eyewear, assistive devices, and medical treatment� ...

. Rebleeding occurs in 4–35% of hyphema cases and is a risk factor for

. Young children with traumatic hyphema are at an increased risk of developing

amblyopia Amblyopia, also called lazy eye, is a disorder of sight in which the brain fails to fully process input from one eye and over time favors the other eye. It results in decreased vision in an eye that typically appears normal in other aspects. Amb ...

, an irreversible condition.

Causes

Hyphemas are frequently caused by injury, and may partially or completely block vision. The most common causes of hyphema are

intraocular surgery Eye surgery, also known as ophthalmic or ocular surgery, is surgery performed on the human eye, eye or its Accessory visual structures, adnexa, by an ophthalmologist or sometimes, an optometrist. Eye surgery is synonymous with ophthalmology. The ...

, blunt trauma, and lacerating trauma. Hyphemas may also occur spontaneously, without any inciting trauma. Spontaneous hyphemas are usually caused by the abnormal growth of blood vessels (

neovascularization Neovascularization is the natural formation of new blood vessels ('' neo-'' + ''vascular'' + '' -ization''), usually in the form of functional microvascular networks, capable of perfusion by red blood cells, that form to serve as collateral circu ...

), tumors of the eye (

retinoblastoma Retinoblastoma (Rb) is a rare form of cancer that rapidly develops from the immature cells of a retina, the light-detecting tissue of the eye. It is the most common primary malignant intraocular cancer in children, and it is almost exclusively fo ...

or iris

melanoma Melanoma, also redundantly known as malignant melanoma, is a type of skin cancer that develops from the pigment-producing cells known as melanocytes. Melanomas typically occur in the skin, but may rarely occur in the mouth, intestines, or eye ( ...

uveitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and ...

, or vascular anomalies (

juvenile xanthogranuloma Juvenile xanthogranuloma is a form of histiocytosis, classified as "non-Langerhans cell histiocytosis", or more specifically, "type 2". It is a rare skin disorder that primarily affects children under one year of age but can also be found in olde ...

). Additional causes of spontaneous hyphema include:

rubeosis iridis Rubeosis iridis is a medical condition of the iris of the eye in which new abnormal blood vessels (formed by neovascularization) are found on the surface of the iris. Causes This condition is often associated with diabetes in advanced proliferativ ...

myotonic dystrophy Myotonic dystrophy (DM) is a type of muscular dystrophy, a group of genetic disorders that cause progressive muscle loss and weakness. In DM, muscles are often unable to relax after contraction. Other manifestations may include cataracts, intel ...

leukemia Leukemia ( also spelled leukaemia and pronounced ) is a group of blood cancers that usually begin in the bone marrow and result in high numbers of abnormal blood cells. These blood cells are not fully developed and are called ''blasts'' or ' ...

hemophilia Haemophilia, or hemophilia (), is a mostly inherited genetic disorder that impairs the body's ability to make blood clots, a process needed to stop bleeding. This results in people bleeding for a longer time after an injury, easy bruising, ...

, and

von Willebrand disease Von Willebrand disease (VWD) is the most common hereditary blood-clotting disorder in humans. An acquired form can sometimes result from other medical conditions. It arises from a deficiency in the quality or quantity of von Willebrand factor ( ...

. Conditions or medications that cause thinning of the blood, such as

aspirin Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat inc ...

warfarin Warfarin, sold under the brand name Coumadin among others, is a medication that is used as an anticoagulant (blood thinner). It is commonly used to prevent blood clots such as deep vein thrombosis and pulmonary embolism, and to prevent strok ...

, or

drinking alcohol Alcohol, sometimes referred to by the chemical name ''ethanol'', is a depressant drug that is the active ingredient in drinks such as beer, wine, and distilled spirits (hard liquor). It is one of the oldest and most commonly consumed recreat ...

may also cause hyphema. Source of bleeding in hyphema with blunt trauma to eye is circulus iridis major artery.

Treatment

The main goals of treatment are to decrease the risk of re-bleeding within the eye, corneal blood staining, and atrophy of the

. Small hyphemas can usually be treated on an outpatient basis. There is little evidence that most of the commonly used treatments for hyphema (antifibrinolytic agents ral and systemic aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid corticosteroids ystemic and topical cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest) are effective at improving visual acuity after two weeks. Surgery may be necessary for non-resolving hyphemas, or hyphemas that are associated with high pressure that does not respond to medication. Surgery can be effective for cleaning out the anterior chamber and preventing corneal blood staining. If pain management is necessary,

acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...

can be used.

Aspirin Aspirin, also known as acetylsalicylic acid (ASA), is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce pain, fever, and/or inflammation, and as an antithrombotic. Specific inflammatory conditions which aspirin is used to treat inc ...

and

ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used for treating pain, fever, and inflammation. This includes painful menstrual periods, migraines, and rheumatoid arthritis. It may also be used to close a patent ductus arte ...

should be avoided, because they interfere with

platelet Platelets, also called thrombocytes (from Greek θρόμβος, "clot" and κύτος, "cell"), are a component of blood whose function (along with the coagulation factors) is to react to bleeding from blood vessel injury by clumping, thereby ini ...

s' ability to form a clot and consequently increase the risk of additional bleeding. Sedation is not usually necessary for patients with hyphema. Aminocaproic or

tranexamic acid Tranexamic acid (TXA) is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken eith ...

s are often prescribed for hyphema on the basis that they reduce the risk of rebleeding by inhibiting the conversion of plasminogen to plasmin, and thereby keeping clots stable. However, the evidence for their effectiveness is limited and aminocaproic acid may actually cause hyphemas to take longer to clear.

Prognosis

Hyphemas require urgent assessment by an optometrist or ophthalmologist as they may result in permanent visual impairment. A long-standing hyphema may result in

hemosiderosis Hemosiderosis is a form of iron overload disorder resulting in the accumulation of hemosiderin. Types include: * Transfusion hemosiderosis * Idiopathic pulmonary hemosiderosis * Transfusional diabetes Organs affected: * Hemosiderin depositi ...

and

heterochromia Heterochromia is a variation in coloration. The term is most often used to describe color differences of the iris, but can also be applied to color variation of hair or skin. Heterochromia is determined by the production, delivery, and concentra ...

. Blood accumulation may also cause an elevation of the

. On average, the increased pressure in the eye remains for six days before dropping. Most uncomplicated hyphemas resolve within 5–6 days.

Epidemiology

As of 2012, the rate of hyphemas in the United States are about 20 cases per 100,000 people annually. The majority of people with a traumatic hyphema are children and young adults. 60% of traumatic hyphemas are sports-related, and there are more cases in males compared to females.

References

External links

Hyphema - Handbook of Ocular Disease Management
{{Bleeding and clotting disorders, us=y Disorders of iris and ciliary body