This week’s Weekly Report comes from Dr Maryam Arshad.
A 26 year old male presented to the ED after being struck in the face with a baseball. His pain was isolated to the right orbit. Physical exam revealed a hyphema occupying approximately one third of his anterior chamber. There was no clinical concern for globe rupture and intraocular pressures were normal. CT scan of the face/orbits was negative.
Question:
What is the pharmacologic treatment for an uncomplicated traumatic hyphema? Is there any role for systemic glucocorticoids?
Hyphema refers to blood that collects in the anterior chamber of the eye. Blunt trauma is the most common cause and most patients have some type of antecedent trauma, but in select patient populations it may also develop spontaneously. Risk factors include the presence of clotting disorders such as von Willebrand disease or sickle cell, and neoplasms such as retinoblastoma. Eye pain and vision loss are the most common presenting complaints.
Initial management of a traumatic hyphema involves ruling out globe rupture. Routine workup including visual acuity, pupillary response, extraocular movements, intraocular pressure, and slit lamp exam should be performed. Corneal abrasions should be ruled out with fluorescein staining. The anterior chamber can then be examined for layering of red blood cells. This may be grossly visible or may require use of the slit lamp.
Hyphemas can be classified by severity:
Grade 1 occupies less than 1/3 of the anterior chamber
Grade 2 occupies 1/3 to ½
Grade 3 occupies more than ½
Grade 4 refers to completely clotted blood
Patients with bleeding disorders should have a CBC and PT/INR checked. CT scan of the orbits should be considered if there is suspicion of intraocular foreign body or globe rupture.
The patient should be placed in a dark room with the head of the bed at 30 degrees to promote settling of red blood cells. Analgesics and anti-emetics should be used without hesitation as pain and vomiting can lead to a rise in intraocular pressure. Tetracaine will provide topical analgesia, facilitating a thorough eye exam. Atropine is an effective cycloplegic and will help with pain relief. Topical steroids such as prednisolone should only be used in consultation with an ophthalmologist but have been shown to prevent rebleeding. The typical dose is prednisolone 1% 1 gtt every hour while awake. Systemic glucocorticoids have not been shown to be of benefit (1). If intraocular pressure is elevated, timolol 0.5% every 12 hours can be used. Acetazolamide can also assist with lowering intraocular pressure but must be used with caution in anyone with the potential to have sickle cell disease as it can promote sickling (2). Ophthalmology follow up should be arranged within 24 hours.
Patient course:
The patient was given analgesics and started on topical steroids after consultation with ophthalmology. Close outpatient follow-up was arranged and the patient was discharged.
References:
1. Brandt MT, Haug R. Traumatic hyphema: A comprehensive review. J Oral Maxillofac Surg. 2001; 59(12):1462-1470.
2. Gharaibeh et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2013; 12:CD005431.
