What is the significance of secondary hemorrhage in patients with hyphema?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Rebleeding into the anterior chamber results in a markedly worse prognosis. Eventual visual recovery to a visual acuity of 20/50 (6/15) or better occurs in approximately 64% of patients with secondary hemorrhage as compared with 79.5% of patients in whom no rebleeding occurred. [6, 11] True secondary bleeding into the anterior chamber is indicated by an obvious increase in the amount of blood in the anterior chamber. Secondary hemorrhage occurs in approximately 25% (range, 7-38%) of all patients with hyphema. [6, 11] The incidence of secondary hemorrhage is higher in hyphemas classified as Grades 3 and 4. [7]

With near total to total hyphemas, in which the blood is dark and clotted, bright red blood often begins to appear at the periphery of the clot on the fourth to the sixth day. This probably results from early dissolution of the clot and does not necessarily indicate a secondary hemorrhage. A large proportion (33%) of patients younger than 6 years has secondary hemorrhages; the likelihood of secondary hemorrhages decreases with age. Secondary hemorrhage usually occurs on the third day or the fourth day, but it may occur from the second day to the seventh day after trauma. [6, 19]

Secondary hemorrhage is probably due to lysis and retraction of the clot and fibrin aggregates that have occluded the initially traumatized vessel. [11] The secondary bleeding may result in increased intraocular pressure and corneal staining and is associated with a poorer visual prognosis. [20, 21]

Several studies have documented that secondary hemorrhage occurs more frequently in African American patients. In 1990, Spoor et al observed secondary hemorrhage in 24.2% of African American patients and in only 4.5% of white patients. [22] Two other studies demonstrated greater rates of secondary hemorrhage in African American patients that are highly significant (P < 0.05). [23, 24] In the initial systemic aminocaproic acid (ACA) study, African American patients comprised 66.2% of the population [11] ; 34% of African American patients in the placebo group developed secondary hemorrhage, and 20% of them had positive sickle cell trait by hemoglobin electrophoresis. There have also been studies showing a higher incidence of rebleeding in cases of hemophilia. [25]

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