s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/survophthal Major review Controversies in the pathophysiology and management of hyphema Svati Bansal, MBBS, MSa, Dinesh Visva Gunasekeran, MBBSb, Bryan Ang, MMedb, Jiaying Lee, MBBSb, Rekha Khandelwal, MBBS, FRCSc, Paul Sullivan, MBBS, FRCOphthd, Rupesh Agrawal, MMed, FRCS (Glasg), FAMS, DNB, DOb,d,e,* a Department of Neuroophthamlology, Singapore National Eye Centre, Singapore, Singapore Department of Ophthalmology, National Healthcare Group Eye Insitute, Tan Tock Seng Hospital, Singapore, Singapore c Department of Ophthalmology, NKP Salve Institute of Medical Sciences, Nagpur, India d Medical Retina Department, Moorfields Eye Hospital, NHS Foundation Trust, London, UK e School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore b article info abstract Article history: Traumatic hyphemas present dilemmas to physicians. There are numerous controversies Received 9 May 2015 pertaining to the optimal approach to traumatic hyphema and no standardized guidelines Received in revised form 12 for its management. We address some of these controversies and present a pragmatic November 2015 approach. We discuss various medical agents and surgical techniques available for treat- Accepted 23 November 2015 ment, along with the indications for their use. We address the complications associated Available online 26 November 2015 with hyphema and how to diagnose and manage them and consider the management of hyphema in special situations such as in children and sickle-cell anemia and in rare Keywords: clinical syndromes such as recurrent hyphema after placement of anterior chamber hyphema intraocular lenses. traumatic glaucoma ª 2016 Elsevier Inc. All rights reserved. surgical drainage angle recession 1. Introduction For hyphema, the accumulation of blood in the anterior chamber, the most common cause is ocular trauma (blunt or penetrating)33,62; however, it can also be seen after intraocular surgery or spontaneously in conditions such as rubeosis iridis, juvenile xanthogranuloma, retinoblastoma, metastatic tumors, iris melanoma, myotonic dystrophy, keratouveitis, leukemia, hemophilia, thrombocytopenia, and Von Willebrand disease.2,6,9,53,60,63,64,74,94 Hyphema can be a herald sign of major intraocular trauma and can itself cause complications such as secondary hemorrhage and glaucoma.103 Even small hyphemas may be associated with significant damage to intraocular tissue. Despite being a common condition, the management protocols for hyphema are still unclear. Conservative management * Corresponding author: Rupesh Agrawal, MMed, FRCS (Glasg), FAMS, DNB, DO, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore 308433. E-mail address: rupesh_agrawal@ttsh.com.sg (R. Agrawal). 0039-6257/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.survophthal.2015.11.005 298 s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 options include bed rest, head elevation, an eye shield, and the use of pharmacologic agents (topical or systemic steroids, antifibrinolytics, cycloplegics, miotics, aspirin, traditional Chinese medicine, and conjugated estrogen).34 Aside from the use of antifibrinolytics to prevent secondary hemorrhage, however, there is no evidence of benefit from the use of these conservative measures.34 Furthermore, there is a lack of consensus regarding a treatment and follow-up strategy targeted at preventing delayed visual loss from complications of hyphema, as well as the management of certain special situations such as concurrent sickle-cell anemia. We aim to address the controversies in the pathophysiology, evaluation, and management of hyphema. Because trauma is the commonest cause, we focus our discussion on closed-globe traumatic hyphema; however, we also analyze special situations such as uveitis, pediatric hyphema, cataract surgery, refractive surgery, and hyphema in patients with sickle-cell anemia. 2. Pathophysiology of hyphema The mean annual incidence rate of traumatic hyphema is estimated as 17/100,000 population in individuals less than 18 years of age1 and 20.7/100,000 population in individuals less than 20 years of age.50 Direct orbital injury resulting in traumatic hyphema usually consists of a high-energy blow to the orbit (61%e66%), impact from a projectile (30.2%e36%), or injury secondary to an explosion (2.4%e3%).50,97 Athletic injuries have become a major cause of traumatic hyphema, whereas accidents at work have become relatively less frequent. Kearns reported that athletic injuries accounted for 39.2% of 314 cases of traumatic hyphema, whereas accidents at work were responsible for 9.9% of the cases.49 The commonest source of blood in hyphema is a tear in the anterior face of the ciliary body.107 A direct blow to the eye can rupture the blood vessels at the root of the iris. The most frequently ruptured vessels are the major arterial circle of the iris and its branches, the recurrent choroidal arteries, and the veins crossing the suprachoroidal space between the ciliary body and episcleral venous plexus.95,107 Blunt injury is also associated with anteroposterior compression of the globe and simultaneous equatorial globe expansion. Equatorial expansion induces stress on anterior chamber angle structures, which may lead to rupture of iris stromal and/or ciliary body vessels with subsequent hemorrhage.22,95 Another possible source of initial hemorrhage is a rapid increase in intraocular pressure (IOP) immediately after the contusive trauma. This eventually leads to rupture of the fragile vasculature of the iris from the pupillary sphincter and/or angle.22 Lacerating injury may be associated with direct damage to blood vessels and hypotony, both of which can precipitate hyphema.107 There is no consensus regarding the predominant source of bleeding (angle vessels or iris sphincter vessels) and their respective risks of rebleeding; however, current opinion is that fragile angle vessels have the higher risk of bleeding as a result of their proximity to the major arterial circle of the iris.22 Delayed hyphema after intraocular surgery may be the result of granulation tissue at the wound margin or caused by damaged uveal vessels (e.g. from surgical trauma or from intraocular lens-induced uveal trauma).63,94 This mechanism should be considered in patients with a history of ocular surgery who present with spontaneous hyphema. In the pediatric age group (less than 18 years of age) hyphemas in the absence of predisposing ocular or systemic disease or medication should arouse the suspicion of nonaccidental injury.59 A significant but rare cause of spontaneous hyphema in children is juvenile xanthogranuloma. Juvenile xanthogranuloma is a predominantly dermatological disorder most commonly presenting in children less than 2 years old characterized by a raised, orange skin lesions occurring either singly or in crops that will regress spontaneously. The most common ocular finding is diffuse or discrete iris nodules that are often quite vascular and may bleed spontaneously. Occasionally, the lesions may present in other areas such as ciliary body, anterior choroid, cornea, lids, and orbit.47 Complications include uveitis and glaucoma, with resulting visual loss and phthisis. Biopsy of skin lesions helps to confirm the diagnosis. The lesions classically contain an infiltrate of lipid-laden histiocytes, lymphocytes, eosinophils, and Touton giant cells. Histologic examination of hyphemas reveals an erythrocyte aggregate enveloped by a pseudocapsule of fibrin-plated coagulum.47 Clot absorption takes place by breakdown of fibrin by fibrinolytic agents and escape of red blood cells through the trabecular meshwork and Schlemm canal.47 Agents that open the trabecular meshwork thus accelerate clot absorption. 3. Clinical features and examination The importance of a detailed history and a thorough ocular and systemic evaluation cannot be stressed enough. The nature of the injury points to the likely type of damage sustained and therefore the prognosis. The priority in trauma is always to stabilize airway, breathing, and circulation, and make an assessment for threats to life. This is followed by an ophthalmic evaluation that includes inspection for gross ocular injury, evaluation of the adnexae, visual acuity, pupillary function, ocular motility, and the position of the globes. Extensive conjunctival chemosis and hemorrhage may indicate an occult scleral rupture (Fig. 1). Proptosis may be secondary to a retrobulbar hematoma, and restriction in ocular motility may suggest an orbital blowout fracture or a contusive head injury. Every attempt should be made to examine the adnexal region carefully and rule out any associated orbital or head trauma. Hyphema can be associated with open-globe (Fig. 2A) or closed-globe injuries. In patients with open-globe injury, primary wound closure is the priority (Fig. 2B). One should not attempt surgical washout of hyphema in open-globe injuries as the blind approach could lead to adverse consequences. Surgical washout can be considered in patients with nonresolving hyphema or sicklecell trait because of the higher risk of secondary glaucoma and permanent visual loss.34 We shall focus on hyphema after closed-globe trauma. s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 299 Table 1 e Grading of hyphema Grade Volume of Diagrammatic representation blood in AC and clinical picture Microhyphema Circulating RBC’s only Fig. 1 e Total hyphema associated with occult scleral dehiscence. Patients should be examined carefully to document and grade the hyphema (Table 1). The following clinical grading system is commonly used in the assessment of traumatic hyphemas: Grade 1dLayered blood occupying less than one-third of the anterior chamber. I <1/3rd of AC II 1/3e1/2 of AC III >1/2 of AC (continued on next page) Fig. 2 e A: Hyphema associated with open-globe injury and iris prolapse and B: hyphema post primary corneal laceration repair. 300 s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 Table 1 e (continued ) Grade Volume of Diagrammatic representation blood in AC and clinical picture IV Total AC, anterior chamber. Grade 2dBlood filling one-third to one-half of the anterior chamber. Grade 3dLayered blood filling one-half to less than total of the anterior chamber. Grade 4dTotal clotted blood, often referred to as “eightball” or “black” hyphema. “Eight ball” or “black hyphema” occurs when the entire anterior chamber is filled with blood, which takes on a darker red color due to the impaired circulation in the aqueous. The term “eight-ball hyphema” or “black-ball hyphema” was coined by Smith and Regan in 1957 (after the dark “eight ball” in snooker)93; however, we have observed that these total hyphemas often still retain a bright or dull red appearance that more closely resembles the “third” or the “eleventh” ball in snooker. Therefore, it may be a worthwhile consideration to revise the traditionally named “eight ball” hyphema to a “redball” or “three-ball hyphema” (Fig. 3). A true dark “eight-ball” hyphema carries a much worse prognosis than a bright red hyphema. In addition to anterior segment examination, an assessment of visual acuity, pupillary reactions, IOP, and extraocular movements must be made. Hyphema may be associated with other signs of anterior segment trauma such as traumatic cataract, damage to the trabecular meshwork, corneat, zonules, and iris (Fig. 4). Fundus examination should be performed at the earliest possible opportunity to rule out concomitant posterior segment trauma such as giant retinal tears that may require prompt intervention. Indirect ophthalmoscopy using scleral depression in an eye with traumatic hyphema is controversial. Clinicians are concerned that pressing on the globe may cause a rebleed by mechanical distraction of the formed clot. The exact pathophysiology behind the rebleed following scleral depression is not well-established. One explanation is a coup-countercoup mechanism similar to that in blunt ocular trauma, which results in clot retraction and causes rebleeding. We recommend gentle scleral depression to examine the peripheral retina in closed-globe injury. This will allow the ophthalmologist to exclude peripheral retinal tears and retinal dialysis, as these complications may require surgical intervention. An exception would be eyes that have had severe contusion, in which case we recommend deferring scleral depression until several weeks have passed. Unlike giant retinal tears, posttraumatic detachments caused by retinal dialysis progress slowly, and indentation may be safely deferred for several months. If scleral depression is not performed, a superfield condensing lens should be used to examine the periphery. Furthermore, B-scan should be done if the hyphema obscures the view of the posterior segment. Radiological investigations (X-ray or computed tomography scans) are required in cases of suspected intraocular foreign body, blowout fracture of the orbit, or head injury. Ultrasound biomicroscopy can identify suspected anterior segment injury not clearly visible on clinical examination. Ultrasound biomicroscopy is a proven ancillary tool useful for ruling out angle recession, iridodialysis or cyclodialysis cleft, and occult foreign body in the anterior chamber. 4. Complications 4.1. Increased intraocular pressure Almost 30% of patients with posttraumatic hyphema have an increased IOP.22 An acute rise in IOP occurs from obstruction of the trabecular meshwork by erythrocytes, fibrin, debris, and platelets. The likelihood of increased IOP is proportionate to the severity of hyphema.17 Secondary glaucoma is seen in 10% of eyes with 50% hyphema, 25% if there is >50% hyphema, and 50% if the hyphema is total.78 Patients with 8-ball hyphema carry a 100% risk of secondary glaucoma; however, 8-ball hyphema is rarely encountered. Fig. 3 e Different shades of red: E, B, and C: old traditional terminology is based on black (eigth) ball of snooker, however as seen in panels B and C, D: there is presence of more bright red color and dull red color in panel D which closely resembles A: Red (third or 11th) of snooker. s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 301 from 45% to 67%.23,42,77 Rebleeding can be recognized clinically by the following characteristics. (1) An increase in the size of the hyphema. (2) Presence of a layer of fresh blood over the older, darker clot in the anterior chamber. (3) Dispersed erythrocytes over the clot after the blood has settled. Fig. 4 e Presence of iridodialysis with hyphema. Late secondary glaucoma may develop weeks to years after hyphema. The incidence of late-onset glaucoma in eyes with a history of traumatic hyphema ranges from 0%e20%.10,101,102 The main causes of late-onset glaucoma are peripheral anterior synechiae formation, increased outflow resistance in angle recession, fibrosis of the trabecular meshwork, and siderosis of the trabecular endothelium. Gonioscopic evaluation is recommended conventionally 7 to 8 days after resolution of hyphema to rule out angle recession; however, like indentation, we prefer to wait for several weeks before attempting gonioscopy. Up to 10% of patients are prone to develop late-onset glaucoma if the degree of angle recession exceeds 180 .12,69,101,102 Angle recession in excess of 270 would further increase the risk of glaucoma. Blanton described 2 periods of elevated IOP, between 2 months and 2 years after the injury and 10 to 15 years after injury. Careful gonioscopy has revealed that between 71% and 86% of traumatized eyes have angle recession.46 The degree of angle recession is not proportional to the amount of hyphema. Some small hyphemas produce large, deep recessions. A recent review by Ng and colleagues demonstrated a statistically significant association between angle recession greater than 180 and the development of glaucoma.46 It has already been recognized in earlier literature that this group of patients should undergo lifelong annual examination to detect late-onset glaucoma66; however, there is no consensus regarding the frequency of follow-up required for patients with angle recession of less than 180 . 4.2. Total and near-total hyphemas often appear dark red. Their color lightens as they start to liquefy and resolve as part of the normal healing process. This change in color should be distinguished from secondary hemorrhage. A significant reduction of vision (<20/200), an initial hyphema of more than one-third of the anterior chamber, and elevated IOP at presentation are significant risk factors for secondary bleeding.58 One-fourth of the patients with grade I hyphemas experience rebleeding into the anterior chamber of the eye, as compared with two-thirds of patients with grade III or IV hyphema.54 There has been shown to be an association of rebleeding with race.44,78 The rates of rebleed are higher in darker skinned persons, especially blacks, when compared with whites. One hypothesis is that melanin interferes with the clearance of erythrocytes from the anterior chamber, causing these differences in rebleeding rates.47 Patients with hemophilia, Von Willebrand disease, and sickle-cell trait also have higher risk of secondary hemorrhage.44,67 4.3. Corneal blood staining Corneal blood staining (Fig. 5) after hyphema has been reported in 2%e11% of cases.11,78,81 The incidence increases in the presence of larger hyphemas, secondary hemorrhage, prolonged clot retraction, sustained increase in IOP, and presence of previous endothelial dysfunction.22,40,79 Read and Goldberg found that an IOP of 25 mm Hg or greater for more than 6 days significantly increases the risk of developing corneal blood staining.80 They subsequently proposed surgical intervention in cases where the hyphema does not decrease Rebleeding (secondary hemorrhage) Rebleeding or secondary hemorrhage occurs in 0.4% to 35% of patients, usually 2e7 days after trauma.32,72,84 This is attributed to lysis and retraction of clot and fibrin within traumatized vessels as part of the subacute healing process.40 It is important to arrange early follow-up to detect this condition as it can significantly alter the visual prognosis through serious complications such as corneal blood staining, amblyopia, secondary glaucoma, and optic atrophy. Estimates of the incidence of glaucoma with rebleeding are high, ranging Fig. 5 e Corneal blood staining. 302 s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 by 50% after day 6.79 Corneal blood staining starts as central straw yellow discoloration of the deep stroma that spreads peripherally. Blood staining causes endothelial decompensation by mechanical disruption of the endothelium and also by photosensitization of the endothelium by hemoglobinderived porphyrins in the presence of light.39,40 The blood staining clears centripetally and may take anywhere from several months to 2 years to clear.15,19 In children, corneal blood staining may be further complicated by amblyopia.15 4.4. Optic atrophy In the setting of posttraumatic hyphema, optic atrophy may develop secondary to traumatic nerve contusion or secondary glaucoma. The risk of developing optic atrophy related to elevated IOP is greater if the pressure is allowed to remain at 50 mm Hg or more for 5 days or 35 mm Hg or more for 7 days in otherwise healthy individuals.80 Patients with sickle-cell disease or trait develop optic atrophy at lower IOPs.89 5. Management of hyphema The management of traumatic hyphema is directed toward accelerating the absorption of the blood and the prevention of complications detailed previously. There is no conclusive evidence that hospital admission, sedation, or complete bed rest with eye patching improves outcomes.22,34,80,109 The indications and advantages of various management options are discussed in the following paragraphs. Bed rest: Some clinicians advocate strict bed rest in hyphema to decrease the chances of secondary hemorrhage; however, studies do not support this, and most have shown no advantage of bed rest over quiet ambulation.10,80 Hospitalization and strict bed rest is mainly advised for patients with severe hyphema, sickle-cell trait/disease, noncompliant patients, children, and patients with bleeding predisposition.91,109 Head elevation allows blood to layer inferiorly. This will promote visual rehabilitation and prevent clot formation in the pupillary axis. Eye patching: Traditionally, eye patching with metal shield protection was advocated until resolution of hyphema. It was believed that the patching increases patient comfort and provides immobilization for proper healing of corneal abrasions if any. Gottsch and colleagues hypothesized that patients with longstanding hyphema and prolonged light exposure might be at risk of developing endothelial dysfunction and corneal blood staining.39,40 Although there is no evidence in the literature to support these claims,34 it is still recommended that patients with hyphema wear a hard plastic shield at all times (including sleep) for the practical purpose of preventing further trauma to the injured eye. Anticoagulant and antiplatelet medications: Anticoagulant (e.g. warfarin sodium, heparin) and antiplatelet (e.g. aspirin, dipyridamole, clopidogrel) medications have not been shown to increase the risk of spontaneous hemorrhage during intraocular surgery.7,27,48 Hence, they do not have to be stopped before this type of surgery. After the occurrence of a hyphema, however, these medications are at risk factors for its persistence or rebleeding. The risk of bleeding complications of anticoagulant medications has been reported to be significantly greater than that of antiplatelet medications.86 Common indications for anticoagulation therapy include atrial fibrillation, prosthetic heart valves, and deep vein thrombosis. Antiplatelet therapy is commonly indicated for the prevention of acute cardiac and cerebrovascular events in at-risk patients.86 Therefore, the decision to stop these medications after the occurrence of hyphema must be made on a case-by-case basis in consultation with the patient’s primary care physician. Evaluation of the patient’s suitability to stop or reduce these medications involves consideration of the desired therapeutic international normalized ratio range for the patient’s medical condition, coexisting medical conditions which may further affect clotting ability (e.g. chronic liver disease, bone marrow suppression), and the time taken for normal clotting and coagulation to be restored after stopping these medications. 5.1. Medical management 5.1.1. Mydriatics and cycloplegics Most studies have not found that the use of mydriatics or cycloplegics in hyphema improves the final visual acuity or prevents the occurrence of complications such as rebleeding.10,34,35,68,80 The use of cycloplegic agents such as topical atropine (an antimuscarinic cycloplegic) decreases the risk of development of posterior synechiae, provides greater comfort in patients with concurrent iritis, and permits visualization of the posterior pole.35 They also have the theoretical benefit of reducing the risk of secondary hemorrhage from the iris or ciliary body by immobilizing these tissues, increasing uveoscleral flow, and preventing the formation of posterior synechia.35 Current recommendations are to use atropine sulphate drops 3 times a day for 2 weeks; however, optimal dosage has yet to be established through formal clinical studies,34 and less frequent dosing should suffice as long as adequate cycloplegia is maintained. That being said, cycloplegics must be used cautiously in patients with narrow angles. 5.1.2. Antifibrinolytic agents Antifibrinolytic agents such as transhexamic acid and aminocaproic acid (ACA) have been proven to lower significantly the rate of rebleeding after traumatic hyphema83,84; however, in most studies, antifibrinolytic agents do not offer any major advantage in preventing most of the complications related to hyphema and may possibly delay clot resorption.34 ACA, a lysine analogue, competitively inactivates plasmin, thereby preventing clot lysis by stabilizing the interface between the clot and vessel wall. Studies reveal that topical ACA is as effective as systemic ACA in reducing the incidence of rebleeding.8 In some studies, ACA was found to decrease the incidence of rebleeding from 22%e33% to 0%e4%.21,65,108 Crouch and Crouch recommended using either systemic ACA (50 mg/kg for 5 days with a maximum dose of 30 g/d) or topical ACA, 1 drop every 4 hours in the affected eye for 5 days in patients with hyphema.19 Topical ACA is safer because it does not cause side effects of systemic ACA such as nausea, vomiting, and hypotension.8,19 The use of ACA is contraindicated in s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 pregnancy (as it is a teratogen), with renal or hepatic dysfunction, and in patients with high thromboembolic risk.8,19 Transhexamic acid, another lysine analogue, has also been shown to inhibit clot fibrinolysis at the site of injured blood vessels.8 We recommend routine prescription of antiemetics with these drugs if systemic preparations are used. 5.1.3. Corticosteroids Topical corticosteroids are useful in preventing rebleeds. They may stabilize the blood-ocular barrier, thereby reducing the influx of plasminogen into the anterior chamber.8,83,84 In addition, the antiinflammatory activity of steroids reduces posterior synechiae formation.34 In a retrospective review of 462 patients treated over 10 years, Ng and colleagues found a statistically significant decrease in the frequency of secondary hemorrhage among patients treated with topical steroids.68 A 5% rebleeding rate was seen for the group of patients treated with topical steroids (with or without cycloplegics) versus a 12% rebleeding rate for the group not treated with topical steroids (with or without cycloplegics). Although a short course of topical steroids is recommended as a first-line therapy for hyphema, they should not be used on a longterm basis because of the risk of steroid-induced glaucoma. The role of oral steroids, however, still remains controversial.73,83,84 Romano and colleagues have suggested that use of a systemic steroid regimen in the Yasuna “No Touch” and “No Touch PLUS” protocols provide the best results in non-Scandinavian populations.83 This protocol, first implemented in 1967, uses 40 mg/day of oral prednisone in divided doses for adults and corresponding doses by weight for children (approximately 0.6 mg/kg). In a series of studies using the Yasuna protocol, the rebleed rate for all patients combined was 0.7%. Farber and colleagues showed that patients treated with systemic steroids had an incidence of secondary hemorrhage equal to that of patients treated with systemic ACA.30 Further randomized, controlled trials are required to determine the efficacy of systemic corticosteroids compared with systemic ACA. From our perspective, oral prednisone can be a reasonable alternative to antifibrinolytic therapy for patients with high rebleed risk (Table 2). For instance, in patients with Von Willebrand disease, elevated IOP associated with the primary or secondary bleed can lead to grave consequences, and oral corticosteroid therapy should be considered. This is particularly relevant in patients with sickle-cell disease or other intravascular clotting disorders and in pregnant patients, as ACA is contraindicated and cannot be prescribed. 5.1.4. Antiglaucoma medication Elevated IOP (greater than 24 mm Hg) can be controlled with topical beta-blockers and carbonic anhydrase inhibitors.8 Acetazolamide lowers plasma pH, which promotes sickling of erythrocytes.8 Therefore, methazolamide is preferred in patients with sickle-cell trait or anemia, as it has a lower propensity for metabolic acidosis compared to acetazolamide.20 Severe, uncontrolled IOP (greater than 35 mm Hg) may require additional systemic medication. 1e1.5 g/Kg of mannitol may be administered intravenously over 45 minutes twice a day.19 Systemic osmotics should be used cautiously in renal dysfunction because they can lead to hemoconcentration. 5.1.5. Aspirin and nonsteroidal antiinflammatory drugs The use of aspirin and other nonsteroidal antiinflammatory drugs significantly increases the risk of secondary hemorrhage owing to their antiplatelet effect.18 The decision to stop these medications has to be made in conjunction with the patient’s general physician. 5.2. Surgical management Our experience is consistent with current evidence that surgical management is only warranted in a small proportion of carefully selected patients, approximately 5% to 7.2% of all patients with hyphema.10,79,97 As a rule, patients with true 8-ball hyphemas require prompt surgical intervention. In other cases it is required only if medical therapy fails (Table 3). Clinical indications for surgical evacuation are persistently elevated IOP, corneal blood staining, and highgrade hyphema. These parameters should therefore be monitored and recorded in the clinical evaluation and follow-up of these patients. We recommend that surgical evacuation be considered according to the empirical criteria proposed by Read and Goldberg as follows26,80: (1) IOP greater than 60 mm Hg for 2 days (to prevent optic atrophy). (2) IOP greater than 24 mm Hg over the first 24 hours or if repeated IOP spikes more than 30 mm Hg in sickle-cell disease or trait. (3) IOP greater than 25 mm Hg with a total hyphema for 5 days (to prevent corneal blood staining). Table 3 e Indications for surgical intervention for hyphema Serial number Table 2 e High-risk factors for rebleed in a patient with hyphema Serial number Predisposing high-risk factor 1 2 3 4 5 6 7 Sickle-cell trait or anemia Secondary hemorrhage Penetrating ocular trauma Suspected child abuse Grade III or IV hyphema Noncompliant patients Intractable glaucoma 303 1 2 3 4 5 Clinical indications for surgical intervention Microscopic corneal blood staining In sickle-cell trait or sickle-cell disease, hyphemas of any size and IOP >24 mm Hg for more than 24 hours Hyphema >1/2 of the anterior chamber for >8 days (to prevent peripheral anterior synechiae) Total hyphema with IOP of >50 mm Hg for 4 days (to prevent optic atrophy) Total hyphema or >3/4 of anterior chamber volume present for 6 days with IOP of >25 mm Hg (to prevent corneal blood staining) IOP, intraocular pressure. 304 s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 (4) Microscopic corneal blood staining. (5) The hyphema fails to resolve to less than 50% of the anterior chamber volume by 8 days (to prevent peripheral anterior synechiae formation). There are varied surgical modalities for management of hyphema depending on the severity and density of hyphema. These will be elaborated on in the following section. 5.2.1. Anterior chamber washout and clot removal The most common surgical approach used is the limbal paracentesis needle drainage. Surgeons may opt to do this as an outpatient procedure. A 27-gauge needle attached to a tuberculin syringe may be used to aspirate the blood slowly. This will only remove liquefied portions of the clot, but is often sufficient to normalize the IOP and restore aqueous flow. Anterior chamber washout using an irrigating Simcoe cannula can be done if the hyphema has not yet organized. When managing organized hyphema, anterior chamber washout using an automated anterior vitrectomy through limbal or clear corneal incisions can be performed. Vitrectomy can debulk the clot without shearing the anatomic structures and causing rebleed. Anterior chamber stability must be maintained (by raising the height of the bottle and through use of cohesive viscoelastic agents), and hypotony should be avoided to minimize subsequent bleeding. The infusion port is used to maintain a constant irrigation and the clot cut and aspirated with the help of a vitrectomy cutter introduced through a clear corneal incision. Care should be taken to avoid iatrogenic trauma to the lens, iris, or corneal endothelium. Viscodissection can be used to separate the adherent hyphema from underlying iris. In addition, the settings of the vitrector should be on irrigate-cut-aspirate rather than irrigateaspirate-cut as the latter setting may result in rebleeding due to traction on the clot and blood vessels. An 8-ball hyphema can be removed with the conventional limbal clot delivery method. 5.2.2. Trabeculectomy and iridectomy Trabeculectomy and iridectomy are useful adjuncts in management of clots associated with large hyphema. Trabeculectomy modulated with either mitomycin C or 5-flurouracil can be combined with clot expression in patients with glaucoma not controlled by maximal medical therapy.41,106 Glaucoma shunts as a primary procedure have shown promising results in such cases as well; however, this surgery may be complicated by postoperative hypotony, choroidal effusion, and secondary hemorrhage41 and is best reserved for patients with intractable glaucoma. In summary, the various surgical methods are associated with significant risks, including damage to corneal endothelium, lens injury, prolapse of intraocular contents, and rebleeding.87 Hence, surgical management should be reserved for carefully selected patients at high risk of developing sight threatening complications. 5.3. Hospitalization and follow-up There are no standardized guidelines for the admission of a patient with hyphema and similarly for frequency of follow- up visits. Both hospitalization and follow up are governed by the degree of hyphema and risk of rebleeding.3,90,109 Patients with high-grade hyphema or high risk of rebleed (Table 2) may be admitted for daily examination and close monitoring. Other patients will benefit from close outpatient follow up on days 2 and 7 to allow early detection of rebleeding (which can occur in up to one-third of patients) or indications for surgical intervention (as outlined in the previous section). Subsequently, once hyphema has resolved and the patient is no longer on topical medication, physicians can safely opt for quarterly follow up to monitor IOP.91 Based on the presence or absence of raised IOP, optic nerve damage, or angle recession, attending physicians can gradually lengthen follow-up intervals. 5.4. Screening for sickle-cell disease or trait in patients of African descent Patients with sickle-cell disease or trait have a higher incidence of secondary hemorrhage, increased IOP, and optic atrophy in the setting of traumatic hyphema compared to nonesickle-cell patients.55,67,89,105 Hence, screening is warranted in patients of African descent.89 Even low-grade hyphema can lead to significant impairment of aqueous outflow, intractable increase in IOP, and optic neuropathy in sickle-cell disease, posing a serious threat to vision.89 6. Special situations 6.1. Sickle-cell hemoglobinopathies As outlined in the previous sections, patients with sickle-cell disease are at significantly elevated risk of developing complications of hyphema. These patients have been found to have enhanced fibrinolysis which explains the predisposition to secondary hemorrhage.43 Furthermore, sickled erythrocytes face greater resistance in passing through the outflow channels of the trabecular meshwork, as they are less pliable than normal biconcave erythrocytes. Hence they slow the process of hyphema resolution and lead to exaggerated increase in IOP.37,38 Making matters worse, patients with sickle-cell disease are susceptible to vascular occlusion at relatively low IOPs or relatively brief durations of high pressures.75 Medical treatment of glaucoma poses a serious challenge in these patients as most commonly used systemic agents are contraindicated.36 Use of hyperosmotic or diuretic agents (e.g., glycerine, isosorbide, and mannitol) should be avoided, as they may cause hemoconcentration and increased blood viscosity in the ocular microvasculature.31,36 Systemic carbonic anhydrase inhibitors cause systemic acidosis in addition to the hemoconcentration, which increases erythrocyte sickling.31 ACA, a carbonic anhydrase inhibitor, increases the concentration of ascorbic acid in aqueous humor and exacerbates the sickling process. This is postulated to be because it acts as a reducing agent.4 A literature search did not reveal any definitive evidence for the risk of systemic acidosis and hemoconcentration from topical carbonic anhydrase inhibitors; however, their local s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 efficacy may be less than that of their systemic counterparts.24 Methazolamide is the only systemic drug that can be used safely for increased IOP in hyphema with background sicklecell disease.20 In conclusion, we recommend treating hyphema aggressively in this subgroup of patients. The IOP should be kept low by using a combination of topical drugs such as timolol, apraclonidine, or brimonidine. Systemic therapy with methazolamide can be considered in recalcitrant cases. Surgical intervention should be instituted earlier and at lower IOP thresholds to prevent optic nerve damage.26 6.2. Management of hyphema in children The management of hyphema in infants and children requires special considerations. First, the possibility of nonaccidental injury or abuse must be considered. Furthermore, nontraumatic etiologies of hyphema such as retinoblastoma, juvenile xanthogranuloma of the iris, and bleeding diathesis from blood dyscrasias such as leukemia should also be explored. Hyphema is a common admitting diagnosis in children sustaining ocular trauma.25 Injury with toys (balls, stones, projectiles) is the predominant etiology.22 The rate of rebleeding of hyphema in children is similar to that in adults.15,22,52 In the past, hospitalization had been recommended for the first few days after the injury15,22,28,52,68; however, few ophthalmologists would advocate hospitalization for hyphema today. Instead, patients can be discharged with emphasis and advice on strict avoidance of physical activity. Children younger than 5 years of age are more likely to develop long term visual impairment secondary to amblyopia from visual deprivation by media opacity (hyphema, traumatic cataract, or corneal blood staining).11 Minimizing the interval between the injury and the restoration of media clarity is hence a priority in these patients. Monocular occlusion after injury to protect against further mechanical injury should be minimized, as the expected benefit must be weighed against the risk of inducing amblyopia in young children. Some authors report the use of systemic steroids with or without topical steroids, instead of ACA, in managing children with traumatic hyphema. This was done with the rationale to control inflammation and reduce the risk of secondary hemorrhage85; however, because of the potential for systemic steroids to interfere with growth, we do not recommend this. Final visual outcome and prognosis of hyphema in children remain similar to adult patients.15,22,25 6.3. Hyphema associated with cataract and refractive surgery Cataract surgery may also be associated with various degrees of hyphema from either surgical trauma or erosion by the haptic of the intraocular lens into the iris.63,94 With manual small incision cataract surgery, there may be hypotony from poor approximation of the wound on the first postoperative day associated with a complete hyphema. With anterior chamber implantable lenses, there is an increase in incidence 305 of hyphema. Some peculiar syndromes described with cataract surgery and associated hyphema are as follows: 6.3.1. Swan syndrome Characterized by recurrent intraocular bleeds even months to years after cataract surgery involving a scleral incision.98 Swan syndrome usually presents with blurred vision with associated mild-to-moderate degree of pain. On examination, there is hyphema or vitreous hemorrhage and neovascularisation of the angle that is best managed by either focal argon laser photocoagulation or direct diathermy of the new vessels or surgical excision of the vessels or scleral wound resuturing. With clear corneal incision cataract surgery becoming more widely used, the incidence of this syndrome has reduced greatly; however, in developing countries where manual small incision cataract surgery is still performed, one may need to consider this entity in cases of recurrent hyphema seen post cataract surgery. 6.4. Uveitis with hyphema Anterior uveitis has been described to be associated with hyphema in cases of Reiter syndrome, juvenile chronic arthritis, ankylosing spondylitis, idiopathic anterior uveitis, and Herpes simplex. In these cases, hyphema has been found to be associated with increased inflammation. Conservative management with topical steroids is the treatment of choice. Bleeding in the anterior chamber (Amsler sign) following paracentesis has been described in Fuchs heterochromic iridocyclitis29 and is also seen in other uveitic cases following anterior chamber decompression. Although not pathognomonic, Amsler sign often occurs in Fuchs heterochromic iridocyclitis from rupturing of the fine rubeotic vessels crossing the trabecular meshwork. These fragile vessels may also lead to hyphema secondary to pressure from gonioscopy or applanation tonometry. 7. Outcome measures Proposed primary outcome measures that can be evaluated in the management of hyphema are visual acuity and stage of hyphema. Secondary outcome measures include the incidence of complications such as corneal blood staining, ocular hypertension requiring surgical intervention, optic atrophy, and rebleeding. Poor visual outcome after resolution of hyphema is often attributed to associated injuries from blunt trauma and is less commonly directly from hyphema.14,49,68,70,76,96,104 Visual outcomes after total hyphema are generally poorer than subtotal hyphema.11,78,80 Varying incidence of glaucoma has been reported in patients with and without rebleeding, with a significantly higher risk in patients with rebleeding.16,23,42,45,51,59,61,88,100 Read and Goldberg found optic atrophy without glaucomatous damage in 6% of eyes in a series of 135 cases.80 Corneal blood staining occurs in 2%e11% of cases of traumatic hyphemas.11,17,80,87 Reported incidence of secondary hemorrhage varies from 2% to 37%5,13,20,21,30,50,54e56,57,67,71,76,80,82,87,92,99 306 8. s u r v e y o f o p h t h a l m o l o g y 6 1 ( 2 0 1 6 ) 2 9 7 e3 0 8 Conclusions and recommendations In summary, hyphema is a common clinical condition that carries a good visual prognosis if managed timely and appropriately (Table 4). A careful systemic and ophthalmic examination to rule out any associated injuries is important. It is also imperative to rule out a history of sickle-cell disease or trait, particularly in African patients with hyphema. Most patients can be followed-up as outpatients on days 2 and 7, with admission reserved for patients with high-grade hyphema or high risk of rebleeding. The primary aim of treatment is to prevent the development of complications. Supportive treatment and medical management with cycloplegics and topical steroids are the mainstay of treatment. Antifibrinolytic agents such as ACA remain an alternative to topical steroids in certain patients, such as children or those with a history of steroid-induced glaucoma; however, if systemic treatment is used, we recommend prescription of antiemetic. Physicians must also remember to exclude contraindications such as history of intravascular clotting disorders or pregnancy. Surgical intervention is reserved for patients who are nonresponsive to medical therapy or at high risk of complications that lead to visual impairment. Secondary hemorrhage and glaucoma are the most common complications. Secondary glaucoma can develop even years after the initial insult; hence, the importance of routine quarterly follow up visits after the primary condition has resolved. Hyphema in children is best managed by head elevation and refraining from physical activity, along with medical management. Shielding the eye should be considered to prevent further mechanical trauma to the eye during the initial healing process. Attending physicians must also be aware of special conditions and syndromes associated with hyphema that impact management strategy. For instance, rare entities such as sickle-cell disease and blood dyscrasias should be kept in mind, especially in patients that develop intractable hyphemas. 8.1. Methods of literature search Articles were selected for review using a search in PubMed, Scopus and MEDLINE database using the key words: Hyphema: Table 4 e Pearls in management of hyphema A B C D E F G H All patients of hyphema should be evaluated in detail for systemic injuries and retained IOFB Absolute bed rest and hospitalization is not mandatory Topical steroids and cycloplegics are used frequently for initial control of inflammation and rebleed Beta blockers and prostaglandin analogues should be used to control IOP Avoid carbonic anhydrase inhibitors, alpha agonists and hyperosmotics in sickle-cell disease/trait Most aggressive treatment is needed to prevent optic nerve damage Recurrent hemorrhage can occur 2e7 days after trauma Regular ophthalmic evaluation is required in patients with angle recession >180 IOFB, intraocular foreign body; IOP, intraocular pressure. “hyphaema”[All Fields] OR “hyphema”[MeSH Terms] OR “hyphema”[All Fields]; Traumatic hyphema: traumatic[All Fields] AND (“hyphaema”[All Fields] OR “hyphema”[MeSH Terms] OR “hyphema”[All Fields]); Spontaneous hyphema: spontaneous[All Fields] AND (“hyphaema”[All Fields] OR “hyphema”[MeSH Terms] OR “hyphema”[All Fields]). 9. Disclosure No financial disclosure or conflict of interest. Acknowledgments All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or nonfinancial interest in the subject matter or materials discussed in this article. Rupesh Agrawal is supported by Clinician Scientist Career Scheme grant awarded by National Healthcare Group (grant number: CSCS/15004), Singapore. references 1. Agapitos PJ, Noel LP, Clarke WN. Traumatic hyphema in children. Ophthalmology. 1987;94:1238 2. Arentsen JJ, Green WR. Melanoma of the iris: report of 72 cases treated surgically. Ophthalmic Surg. 1975;6:23e37 3. Baker RS, Wilson MR, Flowers CW, et al. A population-based survey of work-related ocular injury diagnosis, cause of injury, resource utilization, and hospitalization outcome. Ophthalmic Epidemiol. 1999;6:159 4. Becker B. The effects of the carbonic anhydrase inhibitor, acetazolamide, on the composition of the aqueous humor. 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