Ophthalmic Trauma

Michael Rubin, MD

Department of Ophthalmology and Visual Science

The University of Chicago

Presentation

• 15 y/o AAM presents to the Peds ED

• Boy states the he got hit by a “friend” in the eye last night…

Initial Presentation

• What Questions would you ask this patient?

• How would you examine this patient?

• What tests would you order?

• How would you treat this patient?

• What other problems are you worried about?

What causes a hyphema

• The agent producing a hyphema is usually a projectile that strikes the the eye.

• Various objects have been incriminated, including balls, rocks, projectile toys, air gun pellets, BB gun pellets, and the human fist.

• With the increase of child abuse, fists and belts have started to play a prominent role. Males are involved in three fourths of cases

Spontaneous Hyphema

• Spontaneous hyphemas are secondary to neovascularization (eg, diabetes mellitus, ischemia, cicatrix formation), ocular neoplasms (eg, retinoblastoma), and vascular anomalies (eg, juvenile xanthogranuloma).

Grading a Hyphema

• The following clinical grading system for traumatic hyphemas is preferred:

• Grade 1 - Layered blood occupying less than one third of the anterior chamber

• Grade 2 - Blood filling one third to one half of the anterior chamber

• Grade 3 - Layered blood filling one half to less than total of the anterior chamber

• Grade 4 - Total clotted blood, often referred to as blackball or 8-ball hyphema

Grouping

• 58% involve less than one third of the anterior chamber

• 20% involve one third to one half of the anterior chamber

• 14% involve one half to less than total of the anterior chamber

• 8% are total hyphemas. • 50% of all hyphemas settle inferiorly to form a

level

Mechanism

• Sudden dynamic shift stretches the limbal vessels and displaces the iris and the lens. This displacement may result in a tear at the iris or the ciliary body, usually at the angle structures.

• The blood exits from the anterior chamber via the trabecular meshwork and the Schlemm canal or the juxtacanalicular tissue.

Course

• The usual duration of an uncomplicated hyphema is 5-6 days. The mean duration of elevated intraocular pressure is 6 days.

Increased IOP

• Elevated intraocular pressures (>22 mm Hg) may be anticipated in approximately 32% of all patients with hyphemas.

• Higher, more prolonged elevations of intraocular pressure are more commonly associated with near total or total hyphemas.

Delayed Glaucoma

• Ghost cell glaucoma with hyphema and vitreous hemorrhage may cause elevated intraocular pressure 2 weeks to 3 months after the initial injury

• Gradual clearing of the hyphema occurs, with erythrocytes losing hemoglobin in the vitreous cavity. The ghost cells then circulate forward into the anterior chamber, with resultant trabecular blockage.

Secondary Bleeding

• Secondary bleeding into the anterior chamber results in a markedly worse prognosis.

• Eventual visual recovery to a visual acuity of 20/50 or better occurs in approximately 64% of patients with secondary hemorrhage as compared with 79.5% of patients in whom no rebleeding occurred.

• Secondary hemorrhage occurs in approximately 25% (range, 7-38%) of all patients with hyphema. The incidence of secondary hemorrhage is higher in hyphemas classified as Grades 3 and 4

Race Influence

• Several studies have documented that secondary hemorrhage occurs more frequently in black patients.

• In 1990, Spoor et al observed secondary hemorrhage in 24.2% of black patients and in only 4.5% of Caucasian patients.

Complications of Hyphema

• Complications of traumatic hyphema may be directly attributed to the retention of blood in the anterior chamber.

• The four most significant complications include posterior synechiae, peripheral anterior synechiae, corneal bloodstaining, and optic atrophy.

Corneal Blood Staining

                          

Optic Atrophy

                          

Commotio Retinae

Pre-retinal Heme

Retinal Detachment

Determinants of Prognosis

1. Amount of associated damage to other ocular structures (ie, choroidal rupture, macular scarring)

2. Whether secondary hemorrhage occurs

3. Whether complications of glaucoma, corneal bloodstaining, or optic atrophy occur

Prognosis

• The success of hyphema treatment, as judged by the recovery of visual acuity, is good in approximately 75% of patients.

• Approximately 80% of those with less than one third filling of the anterior chamber regain visual acuity of 20/40 (6/12) or better.

• Approximately 60% of those with a hyphema occupying greater than one half but less than total of the anterior chamber regain visual acuity of 20/40 (6/12) or better.

Modifying Factors

• 35% of those with an initially total hyphema or a Grade 4 hyphema have good visual results.

• 60% of patients younger than 6 years have good visual results.

Treatment

• The customary treatment of patients with traumatic hyphema has included hospitalization, bed rest, bilateral patching, and sedation.

Need to Hospitalize

No statistically significant difference exists in most areas of comparison between patients treated with bed rest, bilateral patches, and sedation and those treated with ambulation, a patch and shield on the injured eye only, and no sedation

Pain Control

• If analgesics are required for pain relief, acetaminophen (Tylenol) with or without codeine, depending on the severity of the pain, is preferred.

• The antiplatelet effect of aspirin tends to increase the incidence of rebleeding in patients with traumatic hyphema and should be strictly avoided.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) share this deleterious antiplatelet effect.

Other therapeutic measures

• The injured globe requires adequate protection with a patch and shield.

• Elevating the head of the bed 30-45° facilitates settling of the hyphema in the inferior anterior chamber and aids in classifying the hyphema.

• Inferior settling facilitates more rapid improvement of visual acuity, earlier evaluation of the posterior pole, and greater clearing of the anterior chamber angle.

Steroids and Cycloplegics

• Steroids after the third day or the fourth day of retained hyphema may be advantageous to decrease the associated iridocyclitis and to prevent or deter the development of peripheral anterior synechiae or posterior synechiae.

• Atropine (1%) is indicated in hyphemas occupying more than 50% of the anterior chamber to break the pupillary block.

AMICAR

• Several double-masked studies clearly establish the value of systemic aminocaproic acid (ACA, AMICAR) in the prevention of recurrent hemorrhages.

• ACA retards clot lysis by preventing plasmin from binding to the lysine in the fibrin clot. As a lysine analog, ACA competitively inactivates plasmin by occupying the site on plasmin that would normally bind to fibrin. In a similar manner, ACA binds to plasminogen, so that when activated to plasmin, it cannot attach to fibrin.

ACA

• In a prospective study by the authors, as well as 2 additional studies, patient groups treated with ACA and placebo were randomized and double-masked (Crouch, 1976; Palmer, 1986; McGetrick, 1983; Kutner, 1987). In the ACA-treated group, the incidence of secondary hemorrhage varied 3-4% (Crouch, 1976; Palmer, 1986; McGetrick, 1983; Kutner, 1987). In the placebo-treated group, the incidence was 28-33%.

Topical ACA

• Topical ACA appears to be a safe, effective treatment to prevent secondary hemorrhage in patients with traumatic hyphema. It is as effective as systemic ACA in reducing secondary hemorrhage, and no systemic adverse effects were observed with topical use. Topical ACA provides an effective outpatient treatment for traumatic hyphemas.

Outpatient Treatment

• Microhyphemas can be treated on an outpatient basis, unless secondary hemorrhage occurs or elevated intraocular pressure is uncontrolled.

• Patients with traumatic hyphema occupying less than one third of the anterior chamber can be treated on an outpatient basis with systemic or topical ACA.

Hospitalization

• If the hyphema occupies more than one third of the anterior chamber, intraocular pressure is elevated beyond 30 mm Hg, or both, hospitalization is recommended.

Indication for Surgery

• Four days after onset of total hyphema • Microscopic corneal bloodstaining• Total hyphema with intraocular

pressures of 50 mm Hg or more for 4 days Total hyphemas or hyphemas filling greater than 75% of the anterior chamber present for 6 days with pressures of 25 mm Hg or more

More surgical indications

• Hyphemas filling greater than 50% of the anterior chamber retained longer than 8-9 days

• In patients with sickle cell trait or sickle cell disease who have hyphemas of any size that are associated with intraocular pressures of greater than 35 mm Hg for more than 24 hours

Sickle Cell

• Patients with sickle cell hemoglobinopathies and even those with sickle cell trait require surgical intervention if intraocular pressure is not controlled within 24 hours