Injuries to the face are commonly encountered when caring for children. We have previously reviewed several facial injury topics (see, Mandibular Fractures, Dental Trauma, Tongue Lacerations, and Eyelid Lacerations).  Eye injuries can sometimes be under appreciated, especially when there are other associated injuries. One simple finding that we should pay particular attention to is the presence of a Hyphema.

Traumatic Hyphema: Basics

• Ocular trauma is a leading cause of non-congenital, monocular blindness in children worldwide. [Yildiz, 2016; SooHoo, 2013]

• Hyphema = blood in the anterior chamber of the eye. [Trief, 2013]
  • Deformity of the globe leads to displacement of the lens and iris, possibly tearing the ciliary body and/or iris vessels.
  • Bleeding will increase the intraocular pressure, which assists tamponading the bleeding along with clot formation.
  • Clot integrity is best 4-7 days after the injury.

• Traumatic hyphema is more common in children than in adults. [SooHoo, 2013; Tries, 2013]
• Most commonly occurs from blunt injury (~75%). [Trief, 2013]
  • Projectiles (like airsoft/BB guns, paintball guns) [Shazly, 2012]
  • Sports
  • Airbags deployed during MVC [Motlery, 2003]
  • Assault, Non-accidental Trauma [Calzada, 2003]
  • Miscellaneous items (hanger, towel, rubber toy snake) [SooHoo, 2013]

Traumatic Hyphema: Complications

• Rebleed / second hemorrhage
  • Associated with a worse prognosis.
  • Typically occurs within first 4 days after injury.
• Corneal staining (~5% of cases)
  • Can lead to amblyopia.
  • May require surgery to resolve.
• Increased intraocular pressure
• Synechiae
• Glaucoma
• Amblyopia
• Visual Impairment [Yildiz, 2016]

Traumatic Hyphema: Evaluation

• Don’t get distracted!
  • Evaluate for other associated traumatic injuries.
  • Evaluate for Open Globe Injuries!
    • The presence of a hyphema should heighten the concern for open globe injury.
    • History of lacerating injuries, small projectiles, or sharp objects also warrants greater concern for open globe injuries.
    • Look specifically for anisocoria and afferent pupillary defect.
    • A portable slit-lamp is a very useful tool!!  Ultrasound, used carefully, can also help evaluate globe integrity.

• Check intraocular pressure
  • Only do this if confident that there is not open globe injury.
  • This can be challenging in children, but is very important.

• Characterizing the hyphema can help communicate to consultants and helps to determine potential risk for complications.  [Trief, 2013]
  • Having patient sit upright will allow hyphema to settle.
  • Hyphemas can be characterized as Microscopic or Macroscopic.
  • Macroscopic hyphemas are graded by the height of the blood in the anterior chamber (AC).
    • Grade 1: Less than 1/3 of the AC; Best prognosis
    • Grade 2: 1/3 to 1/2 of the AC
    • Grade 3: 1/2 to nearly the entire AC
    • Grade 4: Fills the entire AC; Worse prognosis

• Finish the complete eye exam.
  • Fundoscopic exam should be used to look for vitreous hemorrhage. [Trief, 2013]
  • Ultrasound can help characterize the posterior chamber, especially if there is a Grade 3 or 4 hyphema.
  • Visual acuity should also be documented.

• History of Sickle Cell Disease, Sickle Cell Trait or other Bleeding Disorders (Hemophilia, Von Willebrands) should be considered.
  • Patients with sickle cell disease and trait are at risk for developing hyphema, even spontaneously.
  • It is important to inquire about possible sickle cell disease/trait in the family. [Trief, 2013]
  • Patients have been diagnosed with sickle cell disease/trait following traumatic hyphema. [SooHoo, 2013]

Traumatic Hyphema: Treatment

• Outpatient care is most often successful. [SooHoo, 2013]
• Basic care consists of:
  • Head of Bed 30-45 degrees.
  • Relative rest / limited activity
  • Avoiding Aspirin or NSAIDS.
  • Refraining from reading (or watching electronic devices up close) as accommodation can stress the injured vessels. [Trief, 2013]
  • Protective eye shield recommended by some.
  • Close Ophthalmology follow-up (sometimes daily).

• Medication strategies include: [Trief, 2013]
  • Suppress aqueous production
    • Topical Beta Blockers
    • Carbonic anhydrase inhibitors (avoid if Sickle Cell Disease present)
  • Cycloplegics
    • Helps with comfort.
    • May reduced secondary hemorrhage risk.
    • Topical atropine, cyclopentolate, or scopolamine.
  • Steroids
    • Topical or systemic have been used.
    • Help to reduced inflammation and stabilize clot.
    • Avoid long-term use as it will increase risk of cataracts and glaucoma.
  • Antifibrinolytics
    • Decreases rates of secondary bleeding.
    • Aminocaproic acid is commonly used.
    • TXA has been found to be safe, although has less literature to show its benefits. [Albiani, 2008]

• Inpatient care should be considered for patients with:
  • Sickle cell anemia/trait
  • Grade 3 or Grade 4 Hyphema
  • Penetrating ocular trauma
  • Secondary bleed
  • History concerning for abuse
  • Poor ability to adhere to the medical plan.

• Surgery may be required in those who have:
  • Corneal staining
  • Uncontrolled increased intraocular pressures
  • Grade 4 hyphema that persists for >5 days
  • Large clots persisting > 10days

References