Hyphema

Summer, for many, means baseball, hot dogs, and fireworks. But along with the longer days and more outdoor time comes an increased incidence of ocular injuries.

A teenage male reported to our clinic emergently one morning after experiencing a kickball injury the night before (Figure). After initially noting only a slight blur to his vision on the night of the injury, upon waking the following morning, the patient had only light perception vision in the affected eye, precipitating a very concerned call to us from his mother.

MYRIAD CONSEQUENCES

Ocular injuries, and specifically hyphemas, can have myriad visual consequences and complications.^1-3 Two of the main sequelae in cases such as this are caused by increased IOP and corneal blood staining.

Approximately 30% of patients presenting with traumatic hyphema have elevated IOP.³ The pathophysiology behind this is rooted in obstruction of the trabecular meshwork by blood components.^2,3 Increased IOP is seen in 10% of eyes with less than a 50% hyphema, 25% if there is greater than 50% hyphema, and 50% if the hyphema is complete.³ Late traumatic glaucoma may develop weeks to years after the initial injury. The incidence of late-onset glaucoma from hyphema ranges from 0% to 20%.^2,3 There tend to be two periods of elevated IOP, first from 2 months to 2 years after injury, and again at around 10 to 15 years after injury.² Corneal blood staining starts centrally and appears as a yellow hue in the deep stroma. Blood staining may also cause endothelial decompensation and amblyopia in young patients.²

Reasons to consider surgical consultation for traumatic hyphema include the following²:

• The patient has sickle cell disease or trait, and the mean IOP is greater than 24 mm Hg over the first 24 hours or, if treated, the IOP spikes repeatedly over 30 mm Hg;
• The treated IOP is greater than 60 mm Hg for 2 days;
• The treated IOP is greater than 25 mm Hg with a total hyphema for 5 days;
• There is corneal blood staining; or
• The hyphema fails to resolve to less than 50% of anterior chamber volume by 8 days.

COMPLETE RESOLUTION

This patient was treated with atropine and prednisolone acetate and was instructed to maintain vertical head posture, wear an eye shield, and restrict his activity. He returned to 20/20 VA in 1 weeks’ time with complete hyphema resolution and was then allowed to return to normal activity. His IOP remained normal throughout this process. He will continue to be monitored closely for further late onset complications.

As primary eye care providers, let’s all take the time this summer to remind our patients about the need for proper eye protection and the importance of urgent and emergent care by an eye care provider if and when accidents happen.