Operational Medicine 2001
Hyphema

Definition:  Blood in the anterior chamber (front part) of the eye.  This can be a macrohyphma (grossly detectable) or microhyphema (microscopic-magnification needed to observe)

Signs/Symptoms: 

• Pain

• Photophobia

• Blurred vision

• Generally history of blunt trauma

• Macrohyphema or hyphema: 

  • Grossly visible layering of a blood clot in the front part of the eye

• Total hyphema ("eight ball") 

  • Appears dark almost black. 

• Microhyphema:  

  • Red cells suspended in the aqueous of the eye normally viewed with a slit lamp

  • Difficult to see when viewed with a direct ophthalmoscope

  • May appear hazy 

Causes:  Generally occur with trauma associated with fighting, and sports.  Occasionally spontaneous and can sometimes be seen with diseases like diabetes.  

Differential Diagnosis: 

• History of blunt trauma

• Iris tears

• Laser injuries

• Intraocular injuries secondary to penetrating trauma

Evaluation: 

• Visual acuity

• History:

  • Mechanism of the injury

  • Time or injury

  • Was there loss of vision? 

• Ocular exam:

  • Look for ruptured globe. Most common areas of globe rupture: 

    • At limbus

    • Insertion of intraocular muscles

    • Penetrating injury of the eye (corneal laceration).

  • Look at lids and surrounding structures to be sure there is no other associated trauma (lid laceration, fracture of orbital rim). 

  • Estimate the amount of the hyphema and draw as a pictorial validation. 

  • Measure intraocular pressure if possible(as long as there is no presence of a laceration)

• Screen for sickle cell in black patients or patients or mixed race.  

Treatment: 

• Medvac patients that have globe rupture or penetrating injuries as soon as possible.  

• If unable to Medvac,  maintain moistness with normal saline (NOT WATER) and cover loosely with a sterile gauze.

• Medvac patients with elevated intraocular pressure (over 25), and with sickle cell disease/trait with elevated intraocular pressure.  If unable to Medvac then give topical beta-blocker one drop bid. 

• Discontinue, ASA, or NSAIDs

• Acetaminophen 325mg 2 tablets may be used for pain

• For more severe pain acetaminophen 325mg with ˝ gr of codeine.

• Confine to bed rest with bathroom privileges only, no strenuous activity

• If necessary, sedate with mild antihistamine as dyphenhydramine 25mg tid po

• Atropine 1% drops to the affected eye 3 times a day

• Cover eye with a metal or plastic shield to protect eye and for easily observation or a re-bleed.  

Prognosis:  

• Generally good.  

• For microhyphema and small hyphema’s patient should be back to work in 5 days.  

• If trauma is severe, observe patient for the possibility of a traumatic cataract.  

• The most common time for a hyphema re-bleed is on the 3^rd or 4^th day post trauma, but with aggressive bed rest re-bleeds are uncommon.  

• Following the 5^th day the patient should be seen for long term problems associated with anterior segment trauma by an ophthalmologist.    

This section provided by CAPT Robert B. North, Jr., MC, USN

Approved for public release; Distribution is unlimited.

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Operational Medicine 2001
Health Care in Military Settings

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