Oct 31, 2011
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Grade 3 -greater than 1/2 but less than grade 4 (see below)
Grade 4 - Anterior chamber completely filled, also known as 8 ball
hyphema
Causes:
Blunt trauma-most common cause, generally the vessels that join to
iris to the eye
Spontaneous
Lymphoma
Leukemia
Child abuse
Post surgical
Does it matter how much blood accumulates?
Yes a large bleed is worse than a micro bleed but both are really
sentinel events for the potentially worse re-bleed. It is the
re-bleed that carries a higher risk of blindness.
How do you prevent the re-bleed?
Bed rest or light
activity
To prevent a re-bleed into the anterior chamber which may cause
obstruction of vision, or a rise in intraocular pressure. No
reading - movement of the eye can precipitate loosening or loss of
clot.
Elevation of the head of
the bed
Approximately 30 - 45 degrees (so that the hyphema can settle out
inferiorly and avoid obstruction of vision, as well as to
facilitate resolution) laying flat will not cause any permanent
deficit though will cause difficulty seeing or blurry vision.
Wearing of an eye
shield
This prevents accidental rubbing of the eyes, which can precipitate
a re-bleed. DO NOT APPLY PRESSURE TO EYE. Use a
metallic Fox
Shield or paper
cup
Avoidance of
NSAIDS
Aspirin or ibuprofen (which thin the blood and increase the
risk of a re-bleed) - instead, acetaminophen can be used for pain
control.
Sickle Cell
Screen
If African American or Mediterranean check for sickle cell disease,
patients are at increased risk even if just sickle cell trait. MUST
KNOW THIS IS GOING TO GIVE DIAMOX AS IT CAN CAUSE SICKLING.
Medical Treatment
Aminocaproic
acid - to reduce further bleeding
(decreases the likelihood of a re-bleed)
Aminocaproic acid (also known as Amicar,) is a derivative and
analogue of the amino
acid lysine,
which makes it an effective inhibitor for proteolytic enzymes
like plasmin,
the enzyme responsible for fibrinolysis.
For this reason it is effective in treatment of
certain bleeding
disorders .
Cycloplegic eye
drops - to dilate and rest the pupil
The best is atropine because it completely paralyzes the movement
of the iris, where other cyclopleigic drops allow for some
movement.
Check Intraocular Pressure 2 reasons
1. Blood can clog the trabecular
meshwork and cause the IOP to become dangerously high
2. Elevated pressure can cause
blood cells to be forced into the eye causing staining of the
cornea
Elevated Intraocular Pressure Treatment
1. Timolol – B-blocker that
is a aqueous suppressant, quick acting and few side effects
2. Topical carbonic
anhydrase inhibitor -Inhibition of carbonic anhydrase in the
ciliary processes of the eye decreases aqueous humor secretion and
thus lowers the intraocular pressure in the anterior chamber
a. Brinzolamide (trade
name Azopt)
b. Acetazolamide (trade
name Diamox) -
can be given IV in extreme cases
c. Dorzolamide (trade
name Trusopt)
3. Alpha 2 agonists- acts via
decreasing synthesis of aqueous
humor, and increasing the amount that drains from the eye
through uveoscleral outflow
a. Brimonidine (trade
names Alphagan and Alphagan-P)
b. Apraclonidine (trade
name Iopidine)
4. VERY
RARELY- Paracentesis may be preformed
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From the land down under, a must have for every ED: Link to The Emergency Eye Manual
