What is hyphema?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Hyphema is defined as the presence of blood within the aqueous fluid of the anterior chamber. The most common cause of hyphema is trauma.

Postinjury accumulation of blood in the anterior chamber is one of the most challenging clinical problems encountered by the ophthalmologist. Even a small hyphema due to ocular injury can be a sign of major intraocular trauma with associated damage to vascular and other intraocular tissues.

Blunt trauma to the eye may result in injury to the conjunctiva, cornea, iris, pupillary sphincter, angle structures, lens, zonules, retina, vitreous, optic nerve, and other intraocular or intraorbital structures. Blunt trauma associated with a rapid, marked elevation in intraocular pressure with sudden distortion of intraocular structures produces the dynamic changes responsible for hyphema formation.

The lack of an ideal therapeutic program, the potential for secondary hemorrhage, and the secondary onset of glaucoma all threaten to turn an eye with an initially good visual prognosis into a complex therapeutic problem with a poor final visual result.

Classification and characteristics

Traumatic hyphema is encountered in both children and adults. Hyphema is usually the result of a projectile or deliberate blow that hits the exposed portion of the eye despite the protection of the bony orbital rim. Various missiles and objects have been incriminated, including balls, rocks, projectile toys, air gun pellets, BB gun pellets, automobile airbags, hockey pucks, badminton birdies, champagne corks, bungee cords, paint balls, and the human fist. [1, 2, 3] More recently, air gun pellets and BB gun pellets have been made of plastic polymers. There have been reported cases of hyphema due to objects larger than the orbit, such as soccer balls, and even durian fruit falling on the unlucky person napping beneath the durian tree. [4, 5] Slow-motion photography has demonstrated deformation of the soccer balls as impact occurs with the orbital rim, thereby imparting direct pressure to the globe, causing the hyphema. With the increase of child abuse, fists and belts have started to play a prominent role. Males are involved in 75% of traumatic hyphema cases. [6, 7]

Hyphema related to surgical procedures on the eye may occur intraoperatively or postoperatively. Surgical hyphema is a known complication of intraocular surgery and should be managed in a similar manner as traumatic hyphema.

Rarely, spontaneous hyphemas may occur and be confused with traumatic hyphemas. Spontaneous hyphemas are secondary to neovascularization (eg, diabetes mellitus, ischemia, cicatrix formation), ocular neoplasms (eg, retinoblastoma, iris melanomas, medulloepitheliomas, [8] uveitis, and vascular anomalies (eg, juvenile xanthogranuloma). Vascular tufts that exist at the pupillary border have been implicated in spontaneous hyphemas. [9] Spontaneous hyphemas due to iris chafing can be seen with anterior chamber intraocular lenses as in uveitis-glaucoma-hyphema (UGH) syndrome or poorly placed posterior chamber intraocular lenses.

Finally, an idiopathic hyphema of no known cause or recurrence may occur with spontaneous resolution. This is extremely rare.

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