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Glaucoma, Hyphema
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Last Updated: December 1, 2005
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Synonyms and related keywords: hyphema, microhyphema, hemorrhage in the anterior
chamber
AUTHOR INFORMATION Section 1 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Author: Inci Irak, MD, Department of Ophthalmology, Arkansas University, Jones Eye
Institute
Inci Irak, MD, is a member of the following medical societies: American Academy of
Ophthalmology, and American Glaucoma Society
Editor(s): Andrew I Rabinowitz, MD, Consulting Staff, Department of Ophthalmology,
Barnet Dulaney Perkins Eye Center; Donald S Fong, MD, MPH, Assistant Clinical Professor
of Ophthalmology, Director, Clinical Trials Research, Department of Ophthalmology, Southern
California Permanente Medical Group; Martin B Wax, MD, Clinical Professor, Department of
Ophthalmology, University of Texas Southwestern Medical School; Vice President,
Ophthalmology Research and Development, Head, Ophthalmology Discovery Research, Alcon
Labs, Inc; Lance L Brown, OD, MD, Ophthalmologist, Regional Eye Center, Affiliated With
Freeman Hospital and St John's Hospital, Joplin, Missouri; and Hampton Roy, Sr, MD,
Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for
Medical Sciences

Disclosure

INTRODUCTION Section 2 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Background: Hyphema is the collection of red blood cells in the anterior chamber. A
microhyphema occurs when the red blood cells are only detectable microscopically. In a
macroscopic hyphema (hyphema), a visible layer of red blood cells in the anterior chamber
may be detected even without the aid of slit lamp magnification. Complications more
frequently are related to hyphema than microhyphema.

Pathophysiology: Trauma is the most common cause of hyphema; consequently, hyphema

often is seen in younger patients. A blunt, compressive force acting on the globe creates tears
in the ciliary body, iris, and other anterior segment structures. These tears cause shearing of

1
blood vessels, including those that make up the major arterial circle of the anterior segment.
Hyphema also may be caused by intraocular tumors, which may be benign or malignant.

Neovascularization of the iris or ciliary body may result in hyphema. This neovascularization
can be caused by posterior segment ischemia, which usually is associated with microvascular
disease in diabetes. Retinal ischemia also can occur subsequently to retinal arterial or venous
occlusion. Another cause of the neovascularization is carotid stenosis, which can lead to ocular
ischemia. Hyphema also may be iatrogenic in origin; it can occur any time after intraocular
surgery, especially surgery that involves the filtration angle. Certain types of anterior chamber
intraocular lenses used after cataract extraction lend themselves to hyphema, especially rigid
lenses, which is called uveitis-glaucoma-hyphema (UGH) syndrome.

Corneal bloodstaining results from blood being forced into corneal endothelial cells, thereby
"staining" the otherwise clear cornea. Bloodstaining is an ominous sign and often heralds the
need for surgical evacuation of the hyphema.

The intraocular pressure (IOP) rise is related to red blood cells and their byproducts clogging
the trabecular meshwork; another cause is direct trauma to the meshwork, which occurs
concurrently with the initial trauma.

Secondary angle-closure glaucoma that results from pupillary block may also occur. Pupillary
block is seen when the clot completely secludes the pupil/lens interface, thereby blocking the
flow of aqueous from the posterior to the anterior chamber.

Frequency:

• In the US: In North America, the incidence of hyphema is 17-20 cases per 100,000
people per year. The rebleeding rate is 10-20%.

Mortality/Morbidity: Most of the hyphema cases are due to blunt trauma. Less common
causes are systemic diseases and following eye surgery. Spontaneous hyphema is quite rare.
Morbidity of disease depends on underlying pathology, associated diseases, and risk factors.

Race: The African American population has a higher risk for sickle cell hemoglobinopathy.
This group is more likely to have complications of hyphema, including central retinal artery
occlusion.

Sex: Male-to-female ratio is 3:1.

Age: The young population is most affected. Approximately 77% are younger than 30 years.
The peak incidence is in people aged 10-20 years.

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 CLINICAL Section 3 of 11
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History: When a patient presents with a hyphema, the most critical first step is obtaining a
thorough history of the trauma.

• Ascertain mechanism of the injury and type of assaulting object.

• It is important to determine if the patient was wearing protective eyewear at the time of
the trauma.

• The patient's ethnic origin is important. Sickle cell trait/disease is more common in
those patients of African and Mediterranean descent.

• Obtain a good past medical history, including sickle cell hemoglobinopathy, diabetes,
and herpetic infection.

• Past ocular history, including surgery and laser, is important to know.

Physical: The ocular examination should start with a thorough evaluation of the ocular adnexa,
looking for asymmetry.

• Consider the following points during ocular exam:

o In the presence of traumatic hyphema, always consider the possibility of a

coexisting ruptured globe, especially if the IOP is normal or low. If a coexisting
ruptured globe is suspected, perform exploratory surgery and defer the
remainder of the examination until the patient is in the operating room.

o Hyphema may be associated with other clinical entities, and the following
should be suspected in the absence of trauma:
 Rubeosis iridis (proliferative diabetic retinopathy, following central or
branch retinal vessel occlusion, ocular ischemic syndrome)
 Surgery (during or after)
 Iritis (Fuchs heterochromic iridocyclitis, herpes simplex, herpes zoster)
 Intraocular tumors (juvenile xanthogranuloma, retinoblastoma,
malignant melanoma)
 Iris varix, pupillary microhemangiomas
 Following laser trabeculoplasty or iridotomy
 Bleeding disorders

• Full ophthalmic exam includes the following:

o Visual acuity

o Begin evaluation of the iris at the pupillary margin and move outward.

3
  The examiner should look closely for sphincter tears.
 Examine the anterior surface of the iris, which is made of stromal tissue
for the presence of abnormal vessels.
 If the angle is nonoccludable, perform dilation in conjunction with
cycloplegia.
 Carefully examine the vitreous cavity for abnormalities.
 Study the macula, vessels, and periphery.
 Note any evidence of neovascularization of the disc or elsewhere. In
addition, look for evidence of recent or remote vascular occlusion.

o Pupillary reaction - Evaluation of pupillary responses is mandatory to rule out

afferent pupillary damage.

o Extraocular eye movement - Carefully perform motility and ocular alignment to

look for any signs of entrapment.

o Signs of corneal staining - Focus corneal examination on the presence or

absence of bloodstaining.

o Any previous corneal scar

o Red or white blood cells in the anterior chamber

o Anterior segment for signs of inflammation (critical)

o Iris neovascularization, nodules, and heterochromia

o Measure IOP by applanation tonometry. Glaucoma is more likely to develop

with total hyphema or after rebleeding.

o Perform dilated fundus exam as soon as the corneal clarity and hyphema allow a
view of the fundus after dilation.
 Note the presence of vitreous and retinal hemorrhage.
 Document baseline appearance of the optic nerve and color of
neuroretinal rim.
 If the retina cannot be visualized and if retinal breaks and detachment
are suspected, perform ultrasonography earlier.

• Defer gonioscopic exam because it may precipitate rebleeding if hyphema is caused by

trauma otherwise perform dynamic gonioscopy to look for evidence of abnormal
masses or vessels in the filtration angle; additionally, gonioscopy can help reveal the
site of origin of the bleed or a clot in that area. If the patient has an anterior chamber
intraocular lens (IOL), gonioscopic examination of the placement of the footplates in
the angle should be carefully studied.

• Use an exophthalmometer to look for enophthalmos that is related to the ocular trauma.

4
 • If the patient does not have a history of trauma, examine the carotid arteries for a bruit.
This finding may herald ocular ischemic syndrome, as well as neovascularization that
leads to hyphema.

Causes:

• Trauma is the major cause.

• Other causes include the following:

o Rubeosis iridis

o Surgery (during or after)

o Iritis (Fuchs heterochromic iridocyclitis, herpes simplex, herpes zoster)

o Intraocular tumors (juvenile xanthogranuloma, retinoblastoma, malignant

melanoma)

o Iris varix, pupillary microhemangiomas

o Following laser trabeculoplasty or iridotomy

o Sickle cell disease/trait

o UGH syndrome

DIFFERENTIALS Section 4 of 11
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Glaucoma, Uveitic
Juvenile Xanthogranuloma

Other Problems to be Considered:

Hemolytic glaucoma
Ghost cell glaucoma
Hemosiderotic glaucoma

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Introduction
Clinical

5
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
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7
 WORKUP Section 5 of 11
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Lab Studies:

• Sickle cell prep: Screen for sickle cell (mandatory upon presentation for non-Caucasian
patients).

• Hemoglobin electrophoresis: Determine if the patient has sickle cell trait or disease.

• Aqueous samples from the anterior chamber occasionally are needed to differentiate
rare types of glaucoma.

Imaging Studies:

• In selected cases, obtain CT scan of the orbit to exclude associated orbital fracture or
foreign body.

• Perform ultrasonography to rule out vitreous hemorrhage or retinal detachment.

Computerized tomography and ultrasonography may also help in the diagnosis of other
associated eye injuries.

TREATMENT Section 6 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Medical Care: Treatment for microhyphemas in which the IOP is not elevated usually
involves limiting activities that cause rapid movements of the globe during the first 72 hours.

Patients who have concurrent elevation of intraocular pressure may require both topical and
oral ocular hypotensive medications to lower the intraocular pressure. These patients also
require cycloplegia and topical steroids. Non-Caucasian patients should all be screened for

8
sickle cell trait or disease because sickling can lead to obstruction of the central retinal artery
and profound irreversible visual loss.

• Cycloplegics (eg, cyclopentolate tid, atropine qd) and topical steroids (eg, prednisolone
acetate qid) are used to treat associated iritis.
• The use of oral steroids is controversial. Despite their direct antifibrinolytic properties,
no clear benefit in preventing rebleeding has been noted.
• Aminocaproic acid (Amicar), an antifibrinolytic agent, reduces recurrent hyphemas.
Intravenous and oral forms are available; approval for the topical gel form is pending
with the US Food and Drug Administration (FDA).

o If treatment is started within the first 3 days of the occurrence of a hyphema,

aminocaproic acid (50 mg/kg PO q4h for 5 d) has been found to be useful in
decreasing rebleeding. However, adverse effects, such as hypotension, nausea,
renal and hepatic toxicity, limit its use. Also, in total hyphemas, this drug may
delay resorption of blood. In addition, no obvious benefit to improve the final
visual outcome has been noted. Although commercially unavailable, topical
aminocaproic acid may limit systemic adverse effects.
o Another antifibrinolytic agent, tranexamic acid (Cyklokapron), reportedly has
fewer adverse effects than aminocaproic acid but is not available in the United
States.

• IOP reduction usually is necessary, if it is higher than 24 mm Hg in sickle cell patients

or higher than 30 mm Hg for other patients.

o The threshold for treating glaucoma has been reduced in patients with sickle cell
due to their susceptibility to glaucomatous optic nerve damage and central
retinal artery occlusion at even slightly increased pressure. Glaucoma can be
treated with topical medications (eg, beta-blockers [Timoptic bid and new
generation drops]).
o Avoid oral carbonic anhydrase inhibitors, especially acetazolamide (eg,
Diamox), in sickle cell trait or disease patients. These drugs tend to increase
sickling of erythrocytes. Methazolamide may be a better choice in this situation
(Neptazane 50 mg PO q8h).
o Use hyperosmotic agents like IV mannitol for further control.

• Supportive treatment

o Wearing a metal or hard plastic shield at all times (during the day and at night)
is recommended. Patching is recommended when a risk of corneal staining
exists; however, measurements should be taken for occlusion amblyopia.
o Strict bed rest has not been shown to be beneficial.
o Head elevation (up to 30°) helps level the blood inferiorly and keep the central
cornea and pupil aperture clean.
o Aspirin should be avoided to prevent rebleeding.

9
Surgical Care: Corneal bloodstaining is an ominous sign, and these cases often are best
treated with surgical evacuation of the blood. A vitrectomy instrument or an
irrigation/aspiration cannula may be used for this purpose.
All attempts at treating the elevated IOP with medications should be made prior to surgical
wash-out of the hyphema. It is reasonable and helpful to not wash-out the eye until at least 72
hours have transpired to allow for clot formation. If clot formation has not occurred, opening
the eye may simply lead to persistent hemorrhage.

• Indications for anterior chamber wash-out

o Total hyphema does not resolve in 5 days

o IOP remains elevated despite the maximum medical treatment. A normal optic
nerve can tolerate an IOP as high as 50 mm Hg for 5 days. If the patient had
previous optic nerve compromise or a history of sickle cell trait or disease,
consider surgical intervention for elevated IOP above 24 mm Hg that lasts
beyond 1-2 days.

o Decreasing visual acuity

o Signs of corneal bloodstaining

o Increased risk of synechia formation (ie, hyphema filling more than 50% of the
anterior chamber and lasting longer than 8 d)

Consultations: When sickle cell prep or hemoglobin electrophoresis is positive, consultation

with a pediatrician or internist is indicated.

Diet: No special diet is required for patients with hyphema.

Activity:

• Instruct patients to keep activity to a minimum during the first 5 days of hyphema to
reduce the chances of a rebleed. Although no evidence exists regarding ambulation
versus bed rest and whether one is superior to the other in the prevention of rebleeding,
limiting activity is wise to avoid new injuries.

• Hyphemas in children and infants are difficult to treat because preventing a rebleed is
paramount.

o The importance of limiting the child's activity over the first 72 hours cannot be
over emphasized to the caregivers.

o Watching television from a distance of greater than 10 ft is acceptable because

of the minimal eye movement that occurs with viewing a fixed screen at this
distance.

10
11
 MEDICATION Section 7 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Drug Category: Topical beta-blockers -- Decrease aqueous production and IOP.

Timolol maleate 0.25%, 0.5% (Betimol, Timoptic,

Timoptic XE) -- May reduce elevated and normal
Drug Name
IOP, with or without glaucoma, by reducing
production of aqueous humor or by outflow.
Solution: 1 gtt bid
Adult Dose
Gel: 1 gtt qd
Pediatric Dose Not established
Documented hypersensitivity; bronchial asthma;
sinus bradycardia; second- and third-degree AV
Contraindications
block; severe chronic obstructive pulmonary
disease; overt cardiac failure; cardiogenic shock
Oral beta-blockers, quinidine, and verapamil may
increase the systemic side effects of the topical
Interactions beta-blockers; may cause bradycardia and asystole
when used in combination with systemic beta-
blockers (may cause additive effects)
C - Safety for use during pregnancy has not been
Pregnancy
established.
Product may have sulfites, which may cause
Precautions
allergic-type reactions in susceptible patients

Drug Category: Osmotic diuretics -- Decrease the IOP by reducing vitreous volume.

Mannitol (Osmitrol) -- When IOP cannot be

controlled with topical drops and IOP is high
Drug Name
enough to cause optic nerve damage in a short
period of time, osmotic diuretics are indicated.
Adult Dose 1.5-2 g/kg IV infusion as a 20% solution
<12 years: Not established
Pediatric Dose
>12 years: Administer as in adults
Documented hypersensitivity; severe renal
disease; severe pulmonary congestion; active
Contraindications
intracranial bleeding (except during craniotomy);
severe dehydration
Interactions None reported

12
 C - Safety for use during pregnancy has not been
Pregnancy
established.
Carefully evaluate cardiovascular status before
rapid administration of mannitol since a sudden
increase in extracellular fluid may lead to
fulminating CHF; avoid pseudoagglutination,
Precautions
when blood given simultaneously, add at least 20
mEq of sodium chloride to each liter of mannitol
solution; do not give electrolyte-free mannitol
solutions with blood
Isosorbide (Ismotic) -- May be used to abort an
acute attack of glaucoma. In the eyes, may create
an osmotic gradient between plasma and ocular
fluids and induce diuresis by elevating osmolarity
of the glomerular filtrate. These effects may, in
Drug Name
turn, inhibit tubular reabsorption of water.
Treatment is preferred when less risk of nausea
and vomiting than that posed by other oral
hyperosmotic agents is desired. May be preferred,
if the patient tolerates PO intake.
Adult Dose 45% solution: 1-3 g/kg bid/qid
<12 years: Not established
Pediatric Dose
>12 years: Administer as in adults
Documented hypersensitivity; anuria; severe
Contraindications dehydration; frank or impending acute pulmonary
edema; severe cardiac decompensation
Interactions None reported
B - Usually safe but benefits must outweigh the
Pregnancy
risks.
Use repetitive doses with caution, particularly in
Precautions patients with diseases associated with salt
retention
Glycerin/glycerol (Ophthalgan) -- Oral osmotic
agent for reducing IOP. Able to increase tonicity
of blood until finally metabolized and eliminated
Drug Name
by the kidneys. Maximum reduction of IOP
usually occurs 1 h after glycerin administration.
Effect usually lasts approximately 5 h.
Adult Dose 50% solution: 1-2 g/kg PO
<12 years: Not established
Pediatric Dose
>12 years: Administer as in adults
Contraindications Documented hypersensitivity; anuria; severe

13
 dehydration; acute pulmonary edema; severe CHF
Interactions None reported
C - Safety for use during pregnancy has not been
Pregnancy
established.
Administer orally, never parenterally; for oral use
only; avoid in acute urinary retention in
preoperative period; continued use may result in
Precautions weight gain; caution in hypervolemia, diabetes,
severely dehydrated individuals, confused mental
states, congestive heart disease, and cardiac, renal,
or hepatic disease

Drug Category: Antifibrinolytics -- Prevent recurrent hyphema.

Aminocaproic acid (Amicar) -- Inhibits the

substance that converts plasminogen to plasmin.
Drug Name Has antiplasmin activity. Aminocaproic acid is the
most commonly used antifibrinolytic in the United
States.
Adult Dose 50 mg/kg PO q4h
<12 years: Not established
Pediatric Dose
>12 years: Administer as in adults
Documented hypersensitivity; evidence of active
intravascular clotting process; since aminocaproic
Contraindications acid can be fatal in patients with DIC, it is
important to differentiate between
hyperfibrinolysis and DIC
Increase in clotting factors leading to a
Interactions hypercoagulable state may occur with estrogens or
oral contraceptives
C - Safety for use during pregnancy has not been
Pregnancy
established.
Potential adverse effects include GI symptoms,
myopathy, CNS symptoms, skin rash, renal
failure, nausea and vomiting, postural
hypotension, rash, hematuria; when used in
patients with disseminated intravascular
Precautions
coagulation, fatal thrombus formation can occur;
when applied in patients with upper urinary tract
bleeding, blood can convert to heavy clot
formation in the tract and cause renal failure; early
discontinuation may cause rebleeding

14
 Tranexamic acid (Cyklokapron) -- Alternative to
aminocaproic acid. Inhibits fibrinolysis by
displacing plasminogen from fibrin. Hyphema is
Drug Name
not a labeled indication for tranexamic acid use.
More commonly is used in Scandinavian
countries.
Adult Dose 75 mg/kg/d PO divided tid
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions Not established
Pregnancy X - Contraindicated in pregnancy
Caution in renal impairment; visual abnormalities,
Precautions color vision deficiency, and visual field defects
have been reported

Drug Category: Cycloplegics -- Anticholinergic agents block the responses of the iris
sphincter muscle and ciliary body to cholinergic stimulation, producing pupillary dilation
(mydriasis) and paralysis of accommodation (cycloplegia).

Atropine sulfate 0.5%, 1%, 2% (Isopto Atropine,

Atropine sulfate, Atropine-1) -- Acts at
parasympathetic sites in smooth muscle to block
Drug Name
response of sphincter muscle of iris and muscle of
ciliary body to acetylcholine, causing mydriasis
and cycloplegia.
Solution: 1-2 gtt qid; compress lacrimal sac by
Adult Dose digital pressure for 1-3 min after instillation
Ointment: Apply 0.5-ribbon in conjunctival sac tid
Pediatric Dose Solution (0.5%): 1-2 gtt into eye(s) bid/tid
Documented hypersensitivity to belladonna
alkaloids or any component of the products;
Contraindications
thyrotoxicosis; narrow-angle glaucoma;
tachycardia
Coadministration with other anticholinergics have
Interactions
additive effects
C - Safety for use during pregnancy has not been
Pregnancy
established.
May cause CNS disturbances with psychotic
reactions due to hypersensitivity to anticholinergic
Precautions drugs; may cause acute angle-closure glaucoma in
patients with narrow-angle; gonioscopy is
recommended in selected cases before instillation

15
 Cyclopentolate HCl 1% (Cyclogyl) -- Blocks
muscle of ciliary body and sphincter muscle of iris
from responding to cholinergic stimulation, thus
Drug Name
causing mydriasis and cycloplegia.
Induces mydriasis in 30-60 min and cycloplegia in
25-75 min. These effects last up to 24 h.
Adult Dose 1 gtt bid/qid
Pediatric Dose Not established
Documented hypersensitivity; narrow-angle
Contraindications
glaucoma
Decreases effects of carbachol and cholinesterase
Interactions
inhibitors
C - Safety for use during pregnancy has not been
Pregnancy
established.
Exercise caution in patients (eg, elderly patients)
where increased IOP may be present; can cause
toxic anticholinergic systemic adverse effects
(common in children especially infants) but
Precautions
incidence rare when used sparingly; compressing
lacrimal sac by digital pressure for 1-3 min
following application may minimize systemic
absorption
Homatropine 2% and 5% (Isopto Homatropine) --
Blocks responses of sphincter muscle of iris and
Drug Name muscle of ciliary body to cholinergic stimulation,
producing pupillary dilation (mydriasis) and
paralysis of accommodation (cycloplegia).
Adult Dose 1 gtt bid/tid/qid
Pediatric Dose Administer as in adults
Documented hypersensitivity; narrow-angle
Contraindications
glaucoma
Interactions None reported
C - Safety for use during pregnancy has not been
Pregnancy
established.
Caution in elderly patients where increased IOP
may be present; toxic anticholinergic systemic
adverse effects can occur but are rare when used
Precautions sparingly; adverse effects are more common in
children, especially infants; compressing lacrimal
sac by digital pressure for 1-3 min following
instillation minimizes systemic absorption

16
Drug Category: Carbonic anhydrase inhibitors -- Decrease aqueous production and IOP.
These drugs are sulfonamide compounds that decrease the IOP by inhibiting aqueous
production.

Acetazolamide (Diamox) -- Inhibits enzyme

carbonic anhydrase, reducing rate of aqueous
humor formation, which, in turn, reduces IOP.
Used for adjunctive treatment of chronic simple
Drug Name
(open-angle) glaucoma and secondary glaucoma
and preoperatively in acute angle-closure
glaucoma when delay of surgery desired to lower
IOP.
IV forms can be started first for rapid relief: 500
Adult Dose mg IV q6h
250 mg PO q6h
5-10 mg/kg IV q6h
Pediatric Dose
Alternatively, 10-15 mg/kg/d PO divided q6-8h
Documented hypersensitivity to sulfonamides;
Contraindications hypokalemia or hyponatremia; adrenocortical
insufficiency; cirrhosis
Can decrease therapeutic levels of lithium and
Interactions alter excretion of drugs (amphetamines, quinidine,
phenobarbital, salicylates) by alkalinizing urine
C - Safety for use during pregnancy has not been
Pregnancy
established.
Increases sickling in patients with sickle cell trait
or disease (in such cases, methazolamide may be
safer); bone marrow depression,
Precautions
thrombocytopenia, pancytopenia, and hemolytic
anemia may occur; perform baseline CBC and
platelet levels at regular intervals during therapy
Methazolamide (Neptazane, GlaucTabs) --
Reduces aqueous humor formation by inhibiting
Drug Name
enzyme carbonic anhydrase, which results in
decreased IOP.
Adult Dose 50-100 mg PO bid/tid
Pediatric Dose Not established
Contraindications Documented hypersensitivity; renal impairment
May increase toxicity of salicylate, digoxin;
coadministration with other diuretics may induce
Interactions hypokalemia; decreases effects of lithium and
alters excretion of other drugs by alkalinizing
urine

17
 C - Safety for use during pregnancy has not been
Pregnancy
established.
Caution in respiratory acidosis and diabetes
mellitus; impairs mental alertness and/or physical
coordination; hematuria, glycosuria, polyuria,
Precautions
hepatic insufficiency, bone marrow suppression,
thrombocytopenia/purpura, agranulocytosis,
urticaria, pruritus, and rash may occur

Drug Category: Newly approved drugs

Bimatoprost ophthalmic solution (Lumigan) -- A

prostamide analogue with ocular hypotensive
activity. Mimics the IOP-lowering activity of
Drug Name
prostamides via the prostamide pathway. Used to
reduce IOP in open-angle glaucoma or ocular
hypertension.
1 gtt of 0.03% solution in affected eye(s) hs; not to
Adult Dose
exceed 1 dose/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions None reported
C - Safety for use during pregnancy has not been
Pregnancy
established.
May cause permanent increase in pigment to iris
(ie, increases brown pigment) and eyelid; may
increase eyelash growth; caution in uveitis or
Precautions
macular edema; do not instill if wearing contact
lenses; safety has not been tested in pediatric
patients
Travoprost ophthalmic solution (Travatan) --
Prostaglandin F2-alpha analog. Selective FP
Drug Name prostanoid receptor agonist believed to reduce IOP
by increasing uveoscleral outflow. Used to treat
open-angle glaucoma or ocular hypertension.
Adult Dose 1 gtt in affected eye(s) hs; not to exceed 1 dose/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; pregnancy
Interactions None reported
C - Safety for use during pregnancy has not been
Pregnancy
established.

18
 Commonly causes ocular hyperemia; may cause
permanent increase in pigment to iris (ie, increases
brown pigment) and eyelid; may increase eyelash
Precautions
growth; caution in uveitis or macular edema; do
not instill if wearing contact lenses; safety has not
been tested in pediatric patients
Unoprostone ophthalmic (Rescula) --
Prostaglandin F2-alpha analog and selective FP
Drug Name prostanoid receptor agonist. Exact mechanism of
action unknown but believed to reduce IOP by
increasing uveoscleral outflow.
Adult Dose 1 gtt in affected eye(s) bid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions None reported
C - Safety for use during pregnancy has not been
Pregnancy
established.
Commonly causes ocular hyperemia; may cause
permanent increase in pigment to iris (ie, increases
brown pigment) and eyelid; may increase eyelash
Precautions
growth; bacterial keratitis may occur; caution in
uveitis or macular edema; do not instill if wearing
contact lenses
FOLLOW-UP Section 8 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Further Inpatient Care:

• The clot is least adherent to the surrounding tissues on the fourth day following the
injury; this is the preferred time for surgery, when it is needed.

• Hyphema may be washed out or removed with a vitrectomy instrument.

• In some cases, trabeculectomy may be necessary to control IOP.

Further Outpatient Care:

• Despite clearing the hyphema, IOP may remain high.

o In these cases, perform serial gonioscopic exam to detect angle recession,

synechia, and sustained blood clot.

o Treat the appearance of the optic nerve and visual field.

19
 o Vitreous hemorrhage and retinal breaks might complicate a case even if the
hyphema clears.

In/Out Patient Meds:

• If the patient tolerates antiglaucoma medications for controlling IOP, keep these
medications.

• As the hyphema clears and IOP decreases, discontinue medications in a stepwise

fashion, starting with the one that has the most systemic side effects.

Complications:

• Corneal bloodstaining is one complication of long-standing hyphema in association

with glaucoma.

o Both hemosiderin and hemoglobin collect in the stroma and give the cornea a
yellowish appearance.

o It usually spontaneously resolves in years. When there is suspicion of corneal

bloodstaining in the early stages, the hyphema should be cleared surgically.
Washing out the anterior chamber long after the incident has been found to be
useful to clear bloodstaining.

o Anterior segment structures can become difficult to visualize.

• Glaucoma may lead to optic atrophy; this is especially true in sickle cell patients.
Always consider early surgical intervention in resistant cases. A long period of high
IOP (ie, 50 mm Hg lasting longer than 5 d) is dangerous.

• The most severe complication of hyphema is not the initial bleed but rather a rebleed,
which is usually seen within 72 hours following the initial trauma. The rebleeding rate
is 10-20%.

o Hyphema resulting from a rebleed usually is more extensive than that seen with
the initial trauma.

o Rebleeding may present as total hyphema with blood filling the entire anterior
chamber, often called 8-ball hyphema. Such significant hemorrhages often lead
to elevated IOPs and corneal bloodstaining. They also are more likely to require
surgical care.

o Peripheral anterior synechia is another complication and is associated with

larger hyphemas and longer durations.

Prognosis:

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 • Prognosis depends on the size of the hyphema. Patients with a small-sized hyphema
have a good prognosis with simple management and treatment.

• Total hyphema is difficult to treat, and visual outcome is usually poor.

• In some studies, final vision was found better than 20/50 in almost 75% of all hyphema
cases.

Patient Education:

• Promote public awareness about wearing goggles in high-risk sports or work

environments.

• For excellent patient education resources, visit eMedicine's Eye and Vision Center and
Glaucoma Center. Also, see eMedicine's patient education articles Hyphema (Bleeding
in Eye), Glaucoma Overview, Glaucoma FAQs, and Understanding Glaucoma
Medications.

MISCELLANEOUS Section 9 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Medical/Legal Pitfalls:

• Failure to identify sickle cell patients

• Sickle preps should be ordered in all cases of spontaneous or traumatic hyphema in

high-risk ethnic groups.

PICTURES Section 10 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

Caption: Picture 1. Layered hyphema from blunt trauma.

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Picture Type: Photo

Caption: Picture 2. Total or 8-ball hyphema.

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eMedicine Zoom View (Interactive!)

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Picture Type: Photo
BIBLIOGRAPHY Section 11 of 11
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Pictures Bibliography

• Campbell D, Shields MB, Liebmann JM: Ghost cell glaucoma. In: Ritch R, Shields B,
Krupin T, eds. The Glaucomas. Vol 2. 1989; 1239-1247.
• Culom RD Jr, Chang B, eds: Hyphema and microhyphema. In: The Wills Eye Manual.
1994; 32-6.
• Drug Facts and Comparisons Staff: Drug Facts and Comparisons. 1999.
• Herschler J, Cobo M: Trauma and elevated intraocular pressure. In: Ritch R, Shields B,
Krupin T, eds. The Glaucomas. Vol 2. 1989; 1225-1237.
• Rahmani B, Jahadi HR: Comparison of tranexamic acid and prednisolone in the
treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1999 Feb;
106(2): 375-9[Medline].
• Shields MB: Glaucomas associated with intraocular hemorrhage and glaucomas
associated with ocular trauma. In: Textbook of Glaucoma. 1992; 381-399.
• Shingleton BJ, Hersh PS: Traumatic hyphema. In: Eye Trauma. 1991; 104-116.
• Walton W, Von Hagen S, Grigorian R: Management of traumatic hyphema. Surv
Ophthalmol 2002 Jul-Aug; 47(4): 297-334[Medline].

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies
daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate
and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and
human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not
warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results
of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug
doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Glaucoma, Hyphema excerpt

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