Ver el código de «Traumatic hyphema»

==Background==
*Grossly visible blood in the anterior chamber of the eye
*Typically caused by [[blunt eye trauma|blunt trauma]] to the orbit 
*Can result in permanent [[vision loss]]
**Outcome dependent on prevention of rebleeding and control of intraocular pressure
*In non-traumatic hyphema, all patients of African decent should be screened for [[sickle cell disease]] with hemoglobin electrophoresis

[[File:Hyphema.jpeg|thumbnail|Hyphema, Grade II-III]]

==Clinical Features==
*[[Vision loss]]
*[[Eye pain]]
*History of trauma to eye
*Direct and consensual photophobia
*[[Nausea/vomiting]]
*Hyphema grading
**Grade I: ≤ 1/3 anterior chamber volume
**Grade II: 1/3-1/2 anterior chamber volume
**Grade III: > 1/2 anterior chamber volume
**Grade IV: total anterior chamber volume, "eight ball hyphema"
*Elevated grading correlates to increase in intraocular pressure<ref>Oldham GW. Hyphema. Jan 6, 2015. http://eyewiki.aao.org/Hyphema#Differential_diagnosis</ref>
**13.5% have IOP increase in Grade I to II
**52% with IOP increase in Grade IV

==Differential Diagnosis==
{{Maxillofacial trauma DDX}}

{{Unilateral red eye DDX}}

===Spontaneous hyphema (non-traumatic hyphema)===
*[[Sickle cell disease]]
*Ocular or laser surgery
*[[HSV]], [[VZV]] [[uveitis]]
*Neoplastic

==Evaluation==
''evaluation is best performed under [[slit-lamp exam]]''
*Blood in anterior chamber
**May only see difference in color of irises if patient is supine because blood layering is gravity dependent
**Blood in anterior chamber only visible on slit lamp is a microhyphema
*[[Vision loss]] / Acuity changes
*Inspect the lids, lashes, lacrimal ducts, and cornea 
**[[Corneal abrasions]] often co-exist
*Assess direct and consensual pupillary response for the presence of a relative afferent pupillary defect
*Assess for [[Ruptured Globe]] which is associated with high energy mechanisms (shrapnel, BB guns, paintballs, etc)
*Check intraocular pressure after [[Globe Rupture]] is excluded
*Inquire about [[coagulopathy|bleeding diathesis]], [[anticoagulant]]/[[NSAID]]/[[aspirin]] use

==Management==
*Elevate head of bed and upright position to layer blood by gravity, open visual field while blood resorbs
*Eye shield
*Pharmacologic control of pain and emesis 
*Weigh risks and benefits of stopping NSAIDs, ASA, anticoagulants
*If [[Glaucoma|IOP elevated]] (>22) the treatment is similar to [[glaucoma]] management except if there is also a concern for a [[retrobulbar hematoma]] as a result of trauma.<ref name="Brandt">Brandt, MT.  Traumatic hyphema: a comprehensive review.  Journal of oral and maxillofacial surgery.  2001; Vol. 59  Issue 12  Page 1462.</ref> Topical and oral treatments include
**[[Acute angle-closure glaucoma#Management|Timolol]]
**[[Acute angle-closure glaucoma#Management|Topical α-adrenergic agonist]]
**[[Acute angle-closure glaucoma|Carbonic anhydrase inhibitors]]
*Consult ophtho regarding:
**Dilation of pupil to avoid '''"pupillary play"''' -constriction and dilation movements of the iris in response to changing lighting, which can stretch the involved iris vessel causing additional bleeding
**Use of topical α-agonists and/or acetazolamide to decrease intraocular pressure (avoid acetazolamide if the patient has sickle cell disease as this increase sickling)
*[[Cycloplegic]] can be given for comfort and to decease pupillary play if globe rupture has been excluded. Options include:
**[[Tropicamide]] (Mydriacyl)
**[[Homatropine]]
**[[Cyclopentolate]] (Cyclogyl, Cylate, Pentolair)
**[[Scopolamine]]
*[[Topical steroid]] 
*Treat any underlying coagulopathy

==Disposition==
*Should be made by the ophthalmologist after examining the patient
**Hyphemas <33% of anterior chamber are frequently managed as outpatients
*Patients being managed as an outpatient should have ophthalmologist referral and consider outpatient screening for spontaneous hyphema due to the association with [[sickle cell disease]] and [[hemophilia]]
*Patients on anticoagulation or antiplatelet agents should be admitted for reversal and observation.<ref name="Brandt" />

===Discharge instructions===
*No reading (accommodation may further stress injured blood vessels)
*Avoid NSAIDs
*Wear hard shield at all times
*Return to ED if rapid increase in size of hyphema or large increase in pain

==Prognosis==
*Rebleeding worsens prognosis as patients are at higher risk of permanent vision loss.
**Occurs 3-5 days after initial incident
**Complicates ~30% of cases
**Populations at highest risk:
***[[Sickle cell disease]] or sickle cell trait
***Bleeding dyscrasia (including aspirin, NSAID, or anticoagulant use)
***Initial intraocular pressure >22 mmHg
***Pediatric patients 

{| class="wikitable" 
| '''Grade'''
| '''Anterior Chamber Filling'''
| '''Normal Vision Prognosis'''
|-
| I
| <33%
| 90%
|-
| II
| 33-50%
| 70%
|-
| III
| >50%
| 50%
|-
| IV
| 100%
| 50%
|}

==See Also==
*[[Blunt orbital trauma]]

==External Links==

==References==
<references/>

[[Category:Ophthalmology]]