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PATIENT STORY

A 22-year-old man was hit in the eye with a baseball and presented to the emergency department with eye pain and redness and decreased visual acuity. There was a collection of blood in his anterior chamber (Figure 26-1) and he was diagnosed with a hyphema. He was given an eye shield for protection, advised to take acetaminophen for pain, and counseled not to engage in sporting activities until his hyphema resolved. He saw his physician daily for the next 2 days, during which his vision improved. His hyphema resolved in 5 days.

FIGURE 26-1

Layering of red blood cells in the anterior chamber following blunt trauma. This grade 1 hyphema has blood filling in less than one-third of the anterior chamber. (Reproduced with permission from Paul D. Comeau.)

INTRODUCTION

Hyphema, blood in the anterior chamber, can be seen following eye trauma or as a result of clotting disturbances, vascular abnormalities, or mass effects from neoplasms. Traumatic hyphema occurs more often in boys and men, often related to work or sports. Hyphema typically resolves in 5 to 7 days, but some cases are complicated by rebleeding.

EPIDEMIOLOGY

  • Eye injuries are common among children, with a rate of 14.31 per 1000 children. Over 60% of injuries occur in males. The most common diagnosis is contusion/abrasion.1

  • Traumatic hyphema is more common in males (20.2 per 100,000) than females (4.1 per 100,000).2

  • Sixty percent of hyphemas result from sports injuries.3 Sports with higher risk for eye injuries include paintball, baseball/softball, basketball, soccer, fishing, ice hockey, racquet sports, fencing, lacrosse, and boxing.

ETIOLOGY AND PATHOPHYSIOLOGY

  • A hyphema is a collection of blood, mostly erythrocytes, that layer within the anterior chamber.

  • Trauma is the most common cause, often resulting from a direct blow from a projectile object such as a ball, air pellet or BB, rock, or fist.

  • Direct force to the eye (blunt trauma) forces the globe inward, distorting the normal architecture.

  • Intraocular pressure rises instantaneously, causing the lens/iris/ciliary body to move posteriorly, thus disrupting the vascularization with resultant bleeding.

  • Intraocular pressure continues to rise, and bleeding stops when this pressure is high enough to compress the bleeding vessels.

  • A fibrin-platelet clot forms and stabilizes in 4 to 7 days; this is eventually broken down by the fibrinolytic system and cleared through the trabecular meshwork.

DIAGNOSIS

The diagnosis of hyphema is clinical, depending on the classic appearance of blood layering in the anterior chamber.

CLINICAL FEATURES

History and physical:

  • Layered blood in the anterior chamber.

  • History of eye trauma or risk factor for nontraumatic hyphema.

  • Increased intraocular pressure (32%).

  • Decreased vision.

  • Hyphemas are classified according to ...

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