How is traumatic macrohyphema graded?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Answer

Answer

The following is the clinical grading system for traumatic macrohyphemas:

  • Grade 1 - Layered blood occupying less than one third of the anterior chamber
  • Grade 2 - Layered blood filling one third to one half of the anterior chamber
  • Grade 3 - Layered blood filling one half to less than the total of the anterior chamber
  • Grade 4 - Total clotted blood, often referred to as blackball or 8-ball hyphema

Most hyphemas fill less than one third of the anterior chamber. When hyphemas are divided into 4 groups according to the amount of filling of the anterior chamber, 58% involve less than one third of the anterior chamber, 20% involve one third to one half of the anterior chamber, 14% involve one half to less than the total of the anterior chamber, and 8% are total hyphemas. Slightly fewer than one half of all hyphemas settle inferiorly to form a level; approximately 40% form a definite clot, usually adherent to the iris stroma; and 10% have a dark clot in contact with the endothelium. This last form may portend a poor outcome and corneal staining.

An alternative method of grading hyphemas involves measuring (in millimeters) the hyphema from the inferior 6-o'clock limbus. This method may help in monitoring the progress of resolution or the occurrence of rebleeding. Digital imaging analysis is also useful and objective but is available in only a few research or academic facilities.

When there is no layering of blood, but blood cells are seen within the anterior chamber, the term microhyphema can be used and graded with the Standardization of Uveitis Nomenclature (SUN) criteria scale for grading anterior segment cells.


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