AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Surgical hyphema is a known risk of intraocular surgery. Hyphema is the presence of red blood cells in the aqueous humor of the anterior chamber. It can be classified as gross hyphema or microscopic hyphema. Gross hyphema can be graded according to the level of blood meniscus in the anterior chamber of the eye. The term microscopic hyphema applies to red blood cells (erythrocytes) that are only visible on careful slit lamp biomicroscope examination with a narrow beam.

The clinical grading system for hyphemas is as follows:

• Grade I - Layered blood occupying less than one third of the anterior chamber
• Grade II - Blood filling one third to one half of the anterior chamber
• Grade III - Layered blood filling one half to less than total of the anterior chamber
• Grade IV - Total clotted blood, often referred to as blackball or 8-ball hyphema

Pathophysiology

Hyphema describes the condition of the aqueous humor when red blood cells form a suspension in it. The layer of the globe between the retina and the sclera is called the choroid. The choroid and the iris are both part of the uveal tract. The ciliary body is mesenchymal in origin and is located immediately posterior to the iris at the junction of the iris root and the posterior choroid. The retina inserts at the pars plana into the ciliary body. The choroid and the iris contain a rich complex of vessels. The pupil is outlined and controlled by a complex set of iridial muscles, sphincters and dilators. These muscles can be ruptured by sharp and/or blunt trauma. This is a frequent source of intraocular hemorrhage (hyphema). In addition, the iris root and/or the ciliary spur is a common location of bleeding from blunt trauma.

Surgical intervention into the eye for anterior segment procedures is accomplished routinely through various approaches. The most commonly used approaches in modern small incision surgery are via the limbus and/or clear cornea. Clear cornea surgery markedly reduces the risk of bleeding from limbal vessels since the cornea in its healthy state is avascular. Scleral tunnel incision is subject to unpredictable hemorrhage, and the incision must be closed carefully with sutures. Self-sealing wounds can be problematic at times, with unexpected hyphema occurring up to 10% of the time.

Hyphema can occur as a result of intraocular surgery, as follows:

• Intraoperative bleeding - Ciliary body or iris injury seen during a peripheral iridectomy, cataract extraction, cyclodialysis, and filtration procedure (laser peripheral iridectomy, especially with YAG laser than with the argon laser; argon laser trabeculoplasty [ALT] not very common)
• Early postoperative bleeding (a traumatized uveal vessel that was in spasm and suddenly dilates; conjunctival bleeding that makes its way into the anterior chamber via a corneoscleral wound or sclerostomy)
• Late postoperative bleeding (new vessels growing across the corneoscleral wound that bleed when manipulated; a uveal wound that is reopened; an intraocular lens [IOL] that causes chronic iris erosion)

Frequency

United States

The incidence of hyphema is 17-20 per 100,000 people per year.

Mortality/Morbidity

Most postsurgical hyphemas are self-limited. They generally tend to be asymptomatic and usually do not cause an extreme elevation of intraocular pressure (IOP). In cases in which the hyphema reduces vision or causes elevated IOP, conservative medical therapy usually allows for resolution of the hyphema. Patients who have had recent glaucoma surgery and develop a hyphema need to be monitored closely. Blood can be a stimulus for early bleb failure.

Race

Patients with African American ancestry may require closer care because they may have sickle cell trait or disease and, thus, have a greater risk of complications.

Age

The older population is frequently affected because most intraocular surgery is performed on elderly patients. Younger patients are at risk for hyphema because of other mechanisms such as trauma.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

Hyphemas may be seen in the early and late postoperative period following cataract surgery, filtration procedure, iridectomy, trabeculectomy, vitrectomy, scleral buckle, laser iridotomy, and, sometimes, ALT. In patients with neovascular glaucoma, the insertion of a tube implant may chafe iris vessels and cause bleeding.

Physical

A careful ophthalmic examination is important.

• The slit lamp examination is the most important tool in making a diagnosis. Careful measures should be used to look at the conjunctiva, the cornea, the anterior chamber, and the iris.
• Hyphemas are classified into 4 grades, as follows:
• • Grade I - Less than one third of the anterior chamber is filled with blood
  • Grade II - One third to one half of the anterior chamber is filled with blood
  • Grade III - One half to nearly total anterior chamber is filled with blood
  • Grade IV - Total or 100% hyphema
• A total or 100% hyphema describes bright red blood filling the anterior chamber. This usually has a better prognosis than an 8-ball hyphema, since there is continuous aqueous circulation in the anterior chamber.
• An 8-ball hyphema refers to blood in the anterior chamber that has clotted and has taken on a black or purple appearance.

Causes

• Early postsurgical hyphemas can be caused by bleeding from the ciliary body, from cut ends of the Schlemm canal, from the iris or iris root, and from the corneoscleral wounds. Wounds located more posteriorly tend to bleed more.
• Iris neovascularization can result in a hyphema.  These vessels are fragile, and manipulation during surgery may result in bleeding.
• Iris manipulation during cataract surgery and tearing of the iris root can also cause a hyphema.
• Late-onset postsurgical hyphemas occur from the fine arborizing neovascular vessels that form in the inner aspect of the cataract incision site. These vessels are fragile and bleed spontaneously after minor trauma. Hyphemas in this setting may be caused by posterior chamber intraocular lens (PCIOL) haptics eroding the ciliary sulcus. Anterior chamber intraocular lens (ACIOL) haptics also may cause bleeding by chafing the iris surface.
• Rubeosis, or iris neovascularization, results in fine vessels that may bleed.
• Uveitis-glaucoma-hyphema (UGH) syndrome is seen weeks to months after surgery. It often is caused by an IOL that is too mobile (ie, a small ACIOL that moves or twirls, an iris-supported IOL, a mobile PCIOL).
• After ALT, bleeding may occur from an inadvertent laser treatment of the iris root vessel or from reflux of blood in the Schlemm canal.
• After a laser iridotomy, bleeding may occur from an inadvertent laser treatment of the iris root vessel.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Trauma
Intraocular surgery
Spontaneous
Iris microhemangiomas, iris varix, and pupillary microhemangiomas
Iris neovascularization
Clotting disorders
Following laser trabeculoplasty or iridotomy

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• In African American patients (non-Caucasian patients), a sickle cell prep should be ordered if a hyphema is seen because the presence of a hyphema in patients with sickle cell trait or disease can produce significant ocular complications. Sickled red blood cells can more easily obstruct the trabecular meshwork and result in a high IOP, even in the presence of a relatively small hyphema. In addition, ischemic complications of the retina and optic nerve are greater in patients with sickle cell trait and disease.
• A hemoglobin electrophoresis is also helpful. It helps distinguish sickle cell trait from disease once the sickle cell prep is positive.

Imaging Studies

• Infrequently, a B-scan and/or a CT scan may be necessary to rule out an intraocular tumor or a foreign body if a thorough examination is not possible and the reasons for postoperative hyphema are not clear.

Other Tests

• Rarely, an iris fluorescein angiogram may be needed if early iris neovascularization is suspected as an underlying cause of the hyphema.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical Care

Since most postsurgical hyphemas are self-limited and asymptomatic, they usually are observed. Early hyphemas are well handled by the trabecular meshwork, and transient rises in the IOP may occur. Unless a significant rise in the IOP occurs, most patients are asymptomatic.

Medical management using pharmacologic agents is used when resorption delay due to excessive debris has caused the IOP to be elevated. Carbonic anhydrase inhibitors or beta-adrenergic blockers are used to lower the IOP, and cycloplegics and corticosteroids are used to reduce iris movement and to treat the intraocular inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided.

The type of IOP-lowering medication used depends on each patient. Patients with sickle cell disease or trait should not be treated with carbonic anhydrase inhibitors, systemically or topically, because these medications may promote further sickling.

A patient with a hyphema who has a normal IOP is treated with corticosteroids and cycloplegics. IOP reduction is usually necessary if it is higher than 24 mm Hg in patients with sickle cell or higher than 30 mm Hg for other patients. The threshold for treating glaucoma is reduced in patients with sickle cell because of their susceptibility to glaucomatous optic nerve damage and central retinal artery occlusion at even slightly increased pressure.

In patients with glaucoma, a compromised trabecular meshwork may also delay in the clearing of the blood. These patients require close follow-up care and treatment.

Surgical Care

Hyphemas may be seen during surgery or within the first 2-3 days after surgery. If bleeding is identified intraoperatively, it must be identified and coagulated if it does not cease on its own.

• An internal sclerostomy is performed as anteriorly as possible to prevent bleeding during filtration surgery.
• An anterior chamber washout is considered depending on the level of IOP, the size of the hyphema, the likelihood of corneal blood staining, and the presence of sickle trait or sickle cell anemia.
• In UGH syndrome, the treatment often is removal of the lens that is causing the problem and replacing it with another lens.
• Indications for surgical intervention in treating hyphemas are outlined below. (An 8-ball hyphema requires prompt surgical intervention.)
• • A large hyphema is present for more than 10 days.
  • A total hyphema is present for more than 5 days, and IOP remains elevated despite the maximum medical treatment. Surgery is indicated when the IOP is 50 mm Hg for 5 days or greater than 35 mm Hg for a more prolonged period of time. If there is prior optic nerve compromise or a history of sickle cell trait or disease, then surgical intervention is needed for elevated IOP above 24 mm Hg present for 1-2 days.
  • Early corneal blood staining is present.
  • Elevated IOP is uncontrolled by medical therapy and poses a threat to damage the optic nerve or cornea or threatens a retinal vascular occlusion. The level and duration of IOP rise that will damage the optic nerve is difficult to quantitate. It also depends on each patient. According to some sources, optic atrophy resulted from IOP greater than or equal to 35 mm Hg being present for 5-14 days. In the case of total hyphemas, corneal blood staining is seen within 6 days in patients with an IOP greater than 25 mm Hg. The appropriate time for surgical intervention should be based on the patient's clinical presentation.

Consultations

• A retina specialist should be consulted if posterior segment pathology is suspected as an element in the postsurgical hyphema.
• If the patient has sickle cell trait or disease, a consultation with an internist is warranted.

Diet

No specific diet recommendations are indicated.

Activity

• If a postsurgical hyphema has occurred, activity is restricted, and the patient is encouraged to rest for 5-7 days with the head of the bed elevated 30-45°.
• Patients should avoid reading or other activities that require saccadic eye movements.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medications include carbonic anhydrase inhibitors, topical beta-blockers, topical alpha-agonists, cycloplegics, corticosteroids, and osmotic diuretics.

Drug Category: Carbonic anhydrase inhibitors

By slowing the formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, it may inhibit carbonic anhydrase in the ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.

Drug Category: Beta-adrenergic blockers

Exact mechanism of ocular antihypertensive action is not established, but it appears to be a reduction of aqueous humor production.

Drug Category: Combined beta-blocker and carbonic anhydrase inhibitors

Exact mechanism of beta-blockers in ocular antihypertensive action not established, but it appears to be a reduction of aqueous humor production.

By slowing formation of bicarbonate ions with subsequent reduction in sodium and fluid transport, carbonic anhydrase inhibitors may inhibit carbonic anhydrase in ciliary processes of the eye. This effect decreases aqueous humor secretion, reducing IOP.

Drug Category: Alpha-adrenergic agonists

Decrease IOP by reducing aqueous humor production.

Drug Category: Cycloplegics

These drugs are anticholinergic agents that cause pupillary dilation (mydriasis) and paralyze accommodation (cycloplegia) by acting on iris sphincter muscles and ciliary body.

Drug Category: Corticosteroids

Have both anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids have profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.

Drug Category: Hyperosmotic diuretics

Lower IOP by creating osmotic gradient between ocular fluids and plasma. They are not for long-term use.

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Young children or patients who are noncompliant require hospital admission for complete bed rest.

Further Outpatient Care

• Patients with a hyphema in the postoperative period generally are observed in an outpatient setting and are examined daily to see if the blood is clearing and whether the IOP has increased.

In/Out Patient Meds

• See Medication.

Complications

• Complications of hyphema include corneal staining and elevated IOP with resultant damage to the angle and optic nerve.
• • Corneal blood staining occurs when hemosiderin collects in the corneal stroma and gives the cornea a yellowish brown appearance; this takes a long time to resolve. The presence of this finding warrants surgical intervention, mostly likely by an anterior chamber washout.
  • Elevated IOP can lead to optic atrophy; this is more of a threat in patients with sickle cell disease or trait.

Prognosis

• Since most postsurgical hyphemas clear spontaneously, the prognosis is usually good.
• Patients with sickle cell disease or trait generally have a more guarded long-term outcome.
• Patients who develop an 8-ball hyphema also carry a graver outcome. They generally develop secondary glaucoma that requires surgical intervention to remove the clot and often a filtration procedure to lower the IOP.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Hyphema (Bleeding in Eye).

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Most surgical hyphemas resolve spontaneously. Those that require medical or surgical intervention need close follow-up care. It is important to monitor these patients closely so that IOP does not rise and no damage occurs to the cornea, the optic nerve, or the drainage system. In rare instances, the postoperative hyphema may be secondary to a previously unrecognized ocular condition, such as a ciliary body melanoma or iris neovascularization, and detection of these entities entails a more thorough examination and other diagnostic tests. It is also imperative to recognize if a patient with a hyphema has sickle cell.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor, Monica Allen, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

• Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. Vol. 5. 1473-1438. 1994:3386-93.
• Becker B, Dunbar HH. Becker-Shaffer's Diagnosis and Therapy of the Glaucomas. 506. 1989:515.
• Ritch R, Shields MB, Krupin T. The Glaucomas. 1989:648, 682, 1324.
• Sharan S, Painter G, Grigg JR. Total hyphema following postoperative enoxaparin (Clexane). Eye. Jul 2005;19(7):827-8. [Medline].
• Shields MB. Textbook of Glaucoma. 1998:356-57, 496, 524, 526.
• Terebuh A, Leen M. Ophthalmology secrets. In: Traumatic Glaucoma and Hyphema. 1997:151-160.

Article Last Updated: Nov 2, 2007