SURVEY OF OPHTHALMOLOGY VOLUME 20 l NUMBER 1 l JULY-AUGUST 1975

THERAPEUTIC REVIEW PHlLlPP.ELLIS,EDlTOR

Medical Treatment of Traumatic

Hyphema
IRVIN S. PILGER, M.D.

Department of Surgery, Division of Ophthalmology, Harbor General Hospital,

Torrance, California and U.C.L.A. School of Medicine. Los Angeles, California

Abstract. Evaluation and treatment of traumatic hyphema uncomplicated by per-

foration or dissolution of the ocular coats, and the goals of immediate and late treat-
ment, are discussed. Results of the authors series of 301 cases are compared to results
of other series. The prognosis depends greatly on the size of the hyphema and the
immediacy of treatment. (Surv Ophthalmol 20:28-34, 1975)

Key Words: angle recession contusion injuries cornea1 blood

staining tibrinolysis hyphema review urokinase

T
raumatic hyphema is often the result into the anterior chamber as well as into the
of a contusion injury to the eye- newly created cleft. Similarly, contusions
ball. Of course, transmission of this forceproducing a tear into the face of the ciliary
through the various tissues of the globe may body, separating the circular and radial
produce other types of injuries as well. Such muscles from the longitudinal, may be ac-
direct injuries may be severe enough to companied by hyphema of greater or lesser
produce rupture of the globe; however, in this degree.
review, we will consider only trauma not com- Numerous authors have established that
plicated by perforation or dissolution of the while small hemorrhages may occur from
ocular coats. small iris tears or sphincter disruption, severe
anterior chamber hemorrhage, especially the
recurrent type, begins most often in this
Pathogenesis anterior portion of the ciliary body external
to the iris root and extends backward toward
Various types of injuries have been
the major arterial circle, tearing some of its
implicated in the causation of hyphema.8~s2~3s branches.8J6J3
Thus, if the iris root is torn away, there may
be considerable hemorrhage into both the
Treatment
anterior and posterior chambers.
Cyclodialysis, separation of the ciliary body Treatment of traumatic hyphema resolves
from the scleral spur, may initiate bleeding itself into two stages: immediate and late.
THERAPEUTIC REVIEW 29

OBJECTIVES METHODS
Immediate Treatment Medical Treatment
The goals of immediate treatment are: 1) to Many articles 1.4,7~14,18-20
have been written
hasten the absorption of blood from the on management of traumatic hyphema, and
anterior chamber; 2) to prevent recurrent the authors have arrived at various con-
bleeding; 3) to prevent or control such com- clusions regarding treatment methods. Some
plications from hyphema as glaucoma, cor- are almost diametrically opposed to each
neal blood staining, and iritis; and 4) to treatother. Recommendations regarding patching
associated ocular injuries. include patching of one eye, both eyes or no
For the rational treatment of hyphema it is patch at all. Recommended amounts of
necessary to understand how blood leaves the bedrest include total, partial, and none. There
anterior chamber. Although Duke-Elder and are advocates for the use of cycloplegics,
others have stated that absorption occurs miotics, combinations of both, or neither.
mainly through the anterior surface of the Also mentioned are the use of enzymes orally
iris, others feel that this route is negligible12J5
or by subconjunctival or intramuscular injec-
and that the main pathway is through the tion. Some have recommended treatment by
trabecula. While all authors agree that injection of air into the anterior chamber to
hemolyzed blood is easily evacuated from the tamponade the bleeding vessels while others
anterior chamber, it has also been shown5.12 have recommended use of acetazolamide to
that blood corpuscles may readily disappear lower the intraocular pressure. It should be
without hemolysis. Sinskey and KricheskyzB kept in mind that poor vision in an eye with
showed that anterior chamber outflow traumatic hyphema is not caused by the
through the trabecula and the canal of hyphema itself, but primarily by the
Schlemm is the most likely pathway. They associated ocular injuries. In addition,
noted experimentally that absorption of red because serious complications may occur as
cells in rabbit eyes that had been subjected to the result of rebleeding, prevention of secon-
an iridencleisis was 30% faster than in normal dary hemorrhage is essential. Because these
rabbit eyes. However, there was no significant usually occur within the first week, the initial
rate increase in eyes that had only had iridec- care by the ophthalmologist is crucial to the
tomies. This indicated that the iris played no final visual status of the injured eye.
significant roIe in clearing the anterior In 1967, Darr and Passmore cited 109
chamber of blood. cases of traumatic hyphema, comparing cases
that they treated conservatively - bedrest
late Treatment and binocular patching - to those treated
Late treatment must be directed toward: 1) less strictly. There was a rebleeding rate of
prevention of late glaucoma; and 2) evalua- 5.36% in the former and 32% in the latter.
tion of complications and associated injuries, Other authors2~4~17*28 have listed secondary
such as cataract, subluxated or luxated lens, hemorrhage rates from approximately 5% to
retinal changes including detachment, and as high as 40%. However; many of these
damage to the angle structures. reports cannot be easily compared, because
Late complications of contusion hyphema there were no indications of the amount of
often represent associated, but not previously blood initially present. Darr and Passmore
recognized, ocular injuries. Thus, glaucoma specifically stated that . . . no selection is
may be the result of an angle recession injury allowed . . . according to the size of the initial
and require continued treatment and observa- hyphema. This approach has complicated
tion as would any chronic glaucoma, the task of arriving at definitive conclusions
Estimates of the incidence of angle recession regarding primary care, because it has been
in traumatic hyphema range from 20% to shown *12~17%1* that the size of the initial
100% 16.29.30 hemorrhage is a major guide to the visual
A dislocated lens or early cataract requires prognosis and should, therefore, be a deter-
observation at regular intervals and ultimate mining factor in its treatment.
surgery is a possibility. Vitreous hemorrhage A plea for more careful classification of
occurs in 515% of eyes with traumatic traumatic hyphema was made by Levekhov
hyphema. Retinal examination24*27 for and Iandiev13 in their review of 697 cases that
dialysis or presence of detachment must not they had treated. The parameters they recom-
be overlooked. mend for consideration are as follows.
30 Surv Ophthalmol, 20 (1) July-August,
1. Cause
a. Trauma (blunt)
b. Non-traumatic
2. Form
a. Primary
b. Secondary
3. Volume of blood
a. Small (up to 4mm)
b. Moderate (4-6mm)
c. Large (7-9mm)
d. Total (over 9mm)
4. Duration
a. Fresh (up to 7 days)
b. Old (7-14 days)
c. Prolonged (over 14 days)
5. Characteristics, such as liquid, clotted, or
mixed
Oksala? stressed that while many authors
use various methods of treatment, generally
the results are about the same. In his own
series, which he treated by liberal methods
as regards activity and ocular patching, treat-
ment modification was altered only by the
presence of a large hyphema. His results
compared very favorably with the more con-
servative methods. Similarly, Rakusin,lg in
1972, categorically stated that prognosis is
directly related to the volume of blood in the
anterior chamber. Small hyphemas (less than
one-half of the anterior chamber) will most
often clear regardless of the treatment used.
More important is the management of
hyphemas larger than one-half of the
chamber. As might be expected, such cases
had the largest percentage of serious
associated ocular injuries leading to a higher
incidence of ultimately poor vision.
Rakusin treated an essentially equal
number of patients with liberal and conser-
vative methods, i.e., patching or no patching,
and total bedrest versus partial or no bed-
rest. There was no significant difference in the
final visual acuities of the two groups; 75% to
85% of each group had final vision of 20/40
or better.
Haveners methodI was to send his
patients home on restricted activity for one
week. If the hyphema was large, the patient
was hospitalized. Similarly, Oksala kept his
patients on partial bedrest with no binocular
patching unless secondary hemorrhage oc-
curred. His patients had visions of 20/40 or
better with a recurrent hemorrhage rate of
only 5.7%.
1975 PILGER
Read and GoldbergzO divided a series of
patients into two groups. One group was
treated with bilateral patching and bedrest.
Patients in the other group were patched uni-
laterally and were allowed to be ambulatory.
The final visual acuities of these groups were
similar, 20/50 or better in 73% and 79%,
respectively.
RakusinlQ also evaluated the use of topical
steroids, enzymes, and acetazolamide. He
found that none of these had a significant
effect on the course of the disease. Zagora32
also discussed the use of subconjunctival and
intramuscular injections of enzymes such as
hyaluronidase and trypsin. Generally, there
seems to be little enthusiasm for this method
among practicing ophthalmologists who treat
a significant number of these injuries. On the
other hand, use of fibrinolysin21*22 (and in
England, Urokinase) for irrigation of the
anterior chamber is popular. Yasuna*
reported on the routine use of oral steroids on
a small series of patients with traumatic
hyphema, but evidence of its effectiveness
needs to be better established. Its general use
does not seem justified at this time.
Prevention and/or Control of Complications
Glaucoma is the most frequent serious
complication of traumatic hyphema.
Glaucoma rarely accompanies the initial
hyphema, but is most often associated with
secondary hemorrhage. A small recurrent
hemorrhage may be harmless, but blood
totally filling the anterior chamber, especially
if black, will usually block the angle enough
to produce a rise in the intraocular pressure.
While this may tamponade the bleeding
vessels, temporarily preventing further
bleeding, the ultimate result of prolonged in-
creased pressure is harmful, because it may
affect the optic nerve and lead to blood stain-
ing of the cornea.
Cornea1 blood staining occurs most fre-
quently in the presence of hyphema accom-
panied by glaucoma. 4,8*12Less commonly, it
may occur in the absence of elevated pressure
when the hyphema persists4 for a long time.
Although well-established cornea1 staining
may significantly interfere with vision, the
iron pigment will ultimately clear from the
cornea. This quite frequently occurs within a
twelve-month period, but it may take as long
as three years.
THERAPEUTIC REVIEW 31

Iritis is a relatively minor complication of TABLE 1

traumatic hyphema. It is usually mild, as in- Age* and sex? dbtribution
dicated by those ophthalmologists12 who use
miotics in their initial treatment, but are Age in years No. Pts. % Pts.
rarely troubled with synechiae. Topical
steroids, often used in combination with an- l-10 131 43.5
tibiotics, are effective in controlling this. 1l-20 66 22.0
When synechiae formation seems imminent 21-30 35 11.6
(in those cases where the pupil can be 3 l-40 15 4.8
41-50 21 6.9
observed), short acting dilators such as
51-60 15 4.8
tropicamide, homatropine, or cyclopentolate over 60 18 6.0
can be used. Atropine or phenylephrine 301
should be avoided until the critical period for
possible secondary hemorrhage has passed (5- *Oldest patient, 76 years; youngest, 18 mos.
7 days). tSex distribution: 88(29%) female; 213(71%) male

Indications for Surgery

TABLE 2
Secondary glaucoma can usually be
controlled with secretory inhibitors such as Causes of eye injury
acetazolamide, and osmotic agents such as
Causes No. Pts. % Pts.
oral glycerol or intravenous mannitol. Oc-
casionally, judicious use of miotics may help. Fist fights 75 25
In most instances the pressure can be con- Rocks 49 16
trolled without surgical intervention. Sticks 20 6.6
Although there are proponents of early sur- Ball 20 6.6
gical removal of clotted blood,23 the prognosis B. B. Gun 14 4.6
for vision is better if surgical intervention can Pipe 10 3.3
be avoided.1,6*gThis is not true, however, if Falls 10 3.3
the pressure cannot be lowered within 24 to Car accident 10 3.3
48 hours. Also, an anterior chamber filled Sling shot 8 2.6
Miscellaneous
with clotted blood may require surgical in-
4 or less each,
tervention despite a normal pressure if a large gun shot, power mower,
clot fills the chamber for several days without bottle caps, shoe heel,
significant hemolysis or change in size. electric cord 65 22
Unknown 20 6.6
Report of Harbor General Hospital
Series
TABLE 3
The records of 301 patients with traumatic
hyphema treated at Harbor General Hospital Ocular complications associated with traumatic
were reviewed. The age and sex distribution hyphema
are shown in Table 1. The follow-up periods
Complication No. %
varied from a few days to as long as five
years. Fig. 1 shows that the greatest number Vitreous hemorrhage 46 15.3
fell within a l- to 12-month period. Cataract 14 4.6
Causes of the injuries varied, but generally Iridodialysis 16 5.2
they fell within the categories noted by other Glaucoma
authors (see Table 2). The most frequent Secondary 30 10
complications are identified in Table 3. Late 18 6
Because gonioscopy was not always done in Pupil changes 24 8
the earlier cases, angle recession injuries are Maculopathy 10 3.3
not listed in our series. (However, gonioscopy Other retinal lesions 8
Lens dislocation 8 f.Z
performed in our more recent cases has
Blow-out fractures 4 1:3
shown some trauma to the angle within a Choroidal rupture 4 1.3
significant percentage of injuries.)
32 SW Ophthalmal, 20 (1) July-August, 1975 PILGER

Treatment time from onset of the injury

was thought to be significant. Most of our
patients were seen within 24 hours of the in-
jury and 94% were seen within two days. Only
A = less than 1 wk.
eighteen patients (6%) were seen after a
120 longer interval and, of these, eight had final
B=l-4wks.
visual acuities of 20/100 or less. Only five
I C cl-12 mos. (28%) achieved 20/40 or better. Our usual
method of treatment consisted of: 1) bilateral
D = l-5 yrs. patching with topical antibiotics, with or
80,
without steroids; 2) absolute bedrest; 3) no
cycloplegics or miotics until after gross
hyphema had cleared (then only if indicated);
and 4) hospitalization for five to seven days.
49 Unless complications developed, this
routine was strictly followed for 273 of our
301 patients. The remaining 28 patients were
treated with atropine combined with
binocular or uniocular patching and bedrest.
In nearly all instances, this modification
resulted either from new house staff rotations
FIG. 1. Follow-up periods for patients in Harbor
General Hospital series. or general uncertainty by the resident as to
the exact protocol to follow. These 28
patients present interesting findings. Eight
had secondary hemorrhages, which were
followed by glaucoma in four cases. In addi-
TABLE 4 tion, anterior chamber irrigations were done
on four eyes, three from the glaucoma group.
Relation of hyphema size to final visual acuity The final visual acuities in these patients were
significantly poorer than in the group as a
Size of Hyphema No. Pts. % Pts.
whole. Only ten (36%) achieved 20/40 or
Hyphema 1/4or less of A.C. better and eight had less than 20/100. Four-
20/40 or better 82 91 teen of our 301 patients developed secondary
20/50 to 20/100 6 6.6 hemorrhages (4.6%); of these, only 2 (2 1.4%)
less than 20/100 2 2+ had visual acuities of 20/40 or better and half
Total 90 obtained less than 20/100, two with no light
Hyphema of VIto % of A.C. perception. This data supports the general
20/40 or better 61 90 impression that secondary hemorrhage has an
20150 to 201100 3 4 unfavorable effect on the traumatized eye.
less than 201200 5 6 Visual acuities were obtained from 275 of
Total 75 the 301 patients, and 214 (78%) achieved
Hyphema over % of A.C.*
20/40 or better 39 75 20/40 or better. Thirty-seven (13%) had less
20150 to 2OflOO 8 16 than 201100; the remaining 24 fell in between.
less than 20/100 5 10 Of the entire 275 patients tested for visual
Total 52 acuity, 61 had less than 20/40 vision. Eigh-
Total Hyphemat teen (29%) of these were from the 28-patient
20140 or better 26 44 group treated with cycloplegics.
20150 to 201100 8 13+ After reviewing our own data and com-
less than 20/ 100 24 41 paring them with other published reports, ad-
Total 58 ditional study seemed warranted. In accor-
dance with Rakusin,lB we further analyzed
*In this group: rebleed in 6
vit. hems. in 8 our series to determine the relationship of the
cataract or dislocated lens in 8 size of the hyphema to the final visual acuity.
tin this group: 6 enucleations In Rakusins group, treated according to the
4 detached retinas size of the hyphema, 78% achieved visual
THERAPEUTIC REVIEW 33

acuity of 20/60 (6/18) or better if one-half or older ones which may already have had a
less of the anterior chamber was filled with secondary hemorrhage or developed a firm
blood, and only 28% did if that volume was clot.
exceeded. Our series showed visual acuity of 3. The conservative method of initial treat-
20/40 or better in 90% and 59%, respectively. ment (binocular patching and absolute
Although Rakusin found no marked bedrest) of small hemorrhages may not be as
difference in the outcome whether mydriatics important as previously thought.
and miotics, alone or in combination, were 4. Use of cycloplegics and/or miotics in
used or not, our patients did much better small hemorrhages is not helpful. In larger
without mydriatics, and it is still our policy hemorrhages, cycloplegics may be harmful.
not to use these drugs in the initial treatment 5. Larger hyphemas are more likely to
of hyphema. Rakusins series showed no lead to secondary hemorrhages and must be
significant difference with patching of one, carefully monitored for development of
both, or neither eye. Because in our group secondary glaucoma. Such eyes also have a
nearly all were treated with initial binocular higher incidence of associated ocular injuries.
patching, no comparison can be made. An ad- These patients require binocular patching and
ditional consideration is that Rakusins visual bedrest.
acuity cut-off level was 6/18 (20/60). We feel 6. Glaucoma should be treated medically
that our level of 20/40 is a more realistic in- with appropriate drugs. If the pressure is not
dex of good functional vision. Although our adequately lowered within 24-48 hours, sur-
final results were slightly more favorable, in gical intervention is mandatory.
general, both series would appear to support 7. Persistent significant organized
Rakusins approach to hyphema treatment hyphema, even with normal intraocular
from the standpoint that the size of the pressure, may require surgical intervention.
hyphema is a major factor in the outcome 8. As soon as feasible, careful search for
(see Table 4). associated ocular injuries and late com-
While our principal concern has been with plications must be made, with regular re-
medical treatment of hyphema, some of our examination desirable in many cases.
patients did require surgical intervention. The
principal indications for surgery were: 1) in-
traocular pressure that could not be lowered
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