With hyphemia, also sometimes written as hyphemia, a bruising occurs in the anterior chamber of the eye. The anterior chamber of the eye is the space between the cornea and the iris. The blood present blocks most or all of the iris and pupil, causing the patient to lose some or all of his vision. A history of trauma or recent eye surgery are the most common risk factors. But certain conditions and medication use also lead to hyphemia. This eye bleeding requires immediate professional medical care. Medication is available, although the majority of patients require one or more surgical procedures to prevent complications. Left untreated, this condition leads to major or complete vision loss.
- Causes: Trauma, eye surgery, medication use or condition
- Symptoms: Bleeding in the anterior chamber of the eye
- Diagnosis and examinations
- Treatment via medication and surgery
- Complications of hyphemia: Glaucoma
- Prognosis is variable
- Prevention of eye trauma
Causes: Trauma, eye surgery, medication use or condition
Trauma
Blunt trauma is the most common cause of hyphemia. The compressive force of the eyeball leads to damage to the iris, the ciliary body, the trabecular meshwork (system for draining aqueous humor), and the vascular system. The trauma may cause blood vessels to rupture, resulting in the accumulation of red blood cells in the anterior chamber of the eye.
Eye surgery
Intraoperative or postoperative hyphemia is a known complication of eye surgery. In rare cases, the placement of an intraocular lens in the anterior chamber of the eye leads to chronic inflammation, secondary iris neovascularization and the recurrent uveitis-glaucoma-hyphemia (UGH) syndrome. In addition, hyphemia is sometimes the result of laser treatment on the eye, such as a YAG laser. The resulting hyphemia is only mild. The patient recovers spontaneously.
Medication use
Hyphemia may occur after the use of substances that alter the function of platelets or thrombin. Some examples of these are the medications ethanol, aspirin and warfarin. This also includes anticoagulants (blood thinners, anticoagulants).
Condition
Hyphemia may also occur with the following conditions:
- abnormal blood vessels
- Von Willebrand’s disease
- a severe inflammation of the iris (iritis)
- an iris melanoma (cancer in the eye)
- an eye infection caused by the herpes virus
- advanced diabetes mellitus
- hemophilia (blood disease due to the lack of clotting factors)
- juvenile xanthogranuloma
- keratouveitis (e.g. herpes zoster)
- leukemia
- myotonic dystrophy (condition involving muscle wasting and weakness)
- rubeosis iridis
- sickle cell anemia
Symptoms: Bleeding in the anterior chamber of the eye
The symptoms associated with hyphemia are variable and dependent on the cause. Patients have reduced vision and the image they see is distorted (metamorphopsia). When hyphemia is the result of trauma, increased intraocular pressure (glaucoma) may occur, causing patients to complain of eye pain, headache and photophobia (hypersensitivity to light). The bleeding is often visible, but when it is small, this is not always the case. The patient may also have a black eye. Sometimes the eye pupil is narrowed (miosis).
Diagnosis and examinations
Eye examination
The ophthalmologist questions the patient about possible eye surgery, the use of anticoagulants, and also about the general medical history. The patient will then receive a general eye examination. The ophthalmologist examines the patient’s visual acuity. He also looks at the pupils and measures the eye pressure via tonometry. He also performs a gonioscopy (inspection of the drainage angle in glaucoma). A CT scan of the eyes and orbit and eye ultrasound are also useful, especially in the case of trauma. Diagnosis is based on a slit lamp examination of the anterior chamber of the eye. The doctor uses this to view the inside of the eye. A major hyphemia can be identified with a penlight examination. It is important to test all African-American patients with hyphemia for sickle cell anemia because the symptoms of hyphemia may also point in that direction.
Differential diagnosis
The doctor may confuse the bleeding in the anterior chamber with the associated symptoms with the following eye disorders:
- Fuchs heterochromic uveitis
- herpes simplex
- herpes zoster iveitis
- juvenile xanthogranuloma
- keratoconjunctivitis, atopic
- melanoma, choroidal
- melanoma, ciliary body
- melanoma, iris
- retinoblastoma
Treatment via medication and surgery
Medication
The ophthalmologist treats uncomplicated hyphemia conservatively, with an eye patch, limited activity, and keeping the head upright as much as possible (also when sleeping). If the hyphemia is the result of trauma, the patient should be monitored regularly because rebleeding easily occurs in the first few days. The patient also receives painkillers. The patient should not take aspirin-containing medicines or NSAIDs, as these increase the risk of further bleeding. Sometimes topical corticosteroids (systemic for severe cases) are necessary. These reduce the associated inflammation, although they sometimes cause rebleeding. Topical cycloplegic drugs (drugs that paralyze the ciliary body) are also useful for patients with significant ciliary body spasm or photophobia (hypersensitivity to light). Beta-blockers and alpha-agonists are used by the ophthalmologist for increased eye pressure. The patient uses the eye drops according to correct eye drop guidelines. Systemic carbonic anedrase inhibitors and hyperosmotic agents (acetazolamide or mannitol) are required if intraocular pressure lowering medications do not work. the ophthalmologist may prescribe other medications. In addition, the ophthalmologist and doctor treat the cause of hyphemia.
Surgery
A majority of patients with hyphemia undergo surgical intervention. The patient usually takes medication for the first four days and if the problem is not resolved, surgery follows. The ophthalmologist treats glaucoma in the event of trauma using laser therapy, a trabeculectomy or a drainage implant.
Complications of hyphemia: Glaucoma
Increased eye pressure, peripheral anterior synechiae (adhesions between eye structures), posterior synechiae, corneal hemorrhage, recurrent hemorrhage, pupillary block and amblyopia (lazy eye in children) are the most common complications of the surgical procedure. If left untreated, acute glaucoma (increased eye pressure) can also quickly occur due to trauma. The threshold for intraocular pressure in sickle cell anemia is lower than in patients without this disease.
Prognosis is variable
The prognosis depends on the cause of hyphemia, the amount of damage that has occurred and also whether the patient has developed an associated complication of hyphemia. These patients receive regular eye examinations to avoid as many complications as possible. An eye pressure measurement is also important because this easily occurs after trauma. Patients with sickle cell anemia are more likely to have eye complications and receive very close eye checks.
Prevention of eye trauma
Many eye injuries can be prevented by wearing safety glasses or other eye protection. Eye protection is necessary during (contact) sports, such as squash, basketball, etc.