I. Definitions and epidemiology
  1. Defined as blood in anterior chamber of eye
  2. Male>female
II. Causes
  1. Sponanteous (often in association with neovascularization e.g. from diabetic retinopathy; also tumors, uveitis, and hemoglobinopathies)
  2. Trauma, due to posterior displacement of tissue causing tears in ciliary body
  3. Recent intraocular surgery
III. Diagnosis and classification
  1. Diagnosis usually made by gross examination
  2. Classificatoin
    1. Grade 1-Blood occupies < 1/3 of anterior chamber
    2. Grade 2-Blood occupies 1/3-1/2 of anterior chamber
    3. Grade 3-Blood occupies > 1/2 of anterior chamber
    4. Grade 4 (aka "8-ball")-Anterior chamber completely filled

IV. Management
  1. Note-most hyphemas resolve spontaneously over initial 4 days
  2. Assess for rupture of globe, which is an ophthalmologic emergency.  Signs include:
    1. Marked decrease in visual acuity
    2. Eccentric pupil
    3. Marked increase or decrease in anterior chamber depth
    4. Visible extrusion of ocular contents
    5. Tenting of sclera
    6. Large circumferential suconjunctival hemorrhage
  3. Grade 1 hyphema-Medical management only
    1. Eye shield or patch
    2. Minimize activity and eye movement (including reading)
    3. Check hyphema and measure introcular pressure daily (may occur as outpatient in most grade 1 cases)
    4. Manage pain and emesis to minimize any increases in intraocular pressure (avoid NSAIDs and aspirin because of bleeding risk)
    5. Consider topical cycloplegics and pupilary dilation with scopolamine or cyclopentolate
    6. Test for hemoglobinopathies if high risk
    7. Systemic epsilon aminocaproic acid (Amicar)-Slows clot lysis by preventing plasmin from binding to fibrin clot lysine; May reduce incidence of hyphema recurrence at dose of 50-100mg/kg Q4h x 5d, max 30g/d; Only for use with hyphema occupying < 75% of anterior chamber; contraindicated in pregnancy or hepatic or renal insufficiency
  4. Grade > 1or intraocular pressure > 30mm Hg-Aggressive medical management, consider ophthalmologic consultation and hospitalization
    1. If hospitalized, raise head of bed to at least 30' to promote posterior pooling of blood to reduce clogging of trabecular meshwork, and improve visual acuity
  5. Indications for surgery
    1. Grade 4 and intraocular pressure 50mm Hg or more for > 4d
    2. Filling of > 75% of anterior chamber and intraocular pressure 25mm Hg or more  for > 6d
    3. Filling of > 50% of anterior chamber and intraocular pressure 25mm Hg or more  for > 8d
    4. Pt has sickle cell trait or disease and intraocular pressure 35mm Hg or more for > 24h
    5. Microscopic corneal bloodstaining
(Sources include Core Content Review of Family Medicine, 2012)