When is outpatient treatment of hyphema indicated?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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With increasing emphasis on cost containment, outpatient management of hyphema has become more popular in recent years. Several studies have demonstrated no significant difference in final visual acuities in patients with smaller hyphemas treated at home or those treated in hospitals. [59, 46, 60, 61, 40, 62]

Microhyphemas can be treated on an outpatient basis, unless secondary hemorrhage occurs or elevated intraocular pressure is uncontrolled. Patients with traumatic hyphema occupying less than one third of the anterior chamber can be treated on an outpatient basis with systemic or topical ACA. If the hyphema occupies more than one third of the anterior chamber, intraocular pressure is elevated beyond 30 mm Hg, or both, hospitalization is sometimes recommended. The decision to hospitalize also depends on the cooperation of the patient, family members, and the extent of ocular injury. For outpatients, daily ocular examinations, including an evaluation of the amount of hyphema and intraocular pressure, should be performed. Daily ophthalmic sketches are helpful in estimating the amount and the rate of resolution or rebleeding. Applanation tonometry must be performed at least once daily and twice daily in patients with elevated intraocular pressures.

Minimal bloodstaining is often difficult to detect against a background of blood in the anterior chamber. Under such circumstances, the cornea often assumes a yellowish cast, which is reflected from the yellowish fibrinous coagulum in the anterior chamber. The most typical early sign of corneal bloodstaining is the presence of tiny yellowish granules that initially appear in the posterior third of the corneal stroma. An additional finding is a lack of definition or a blurred appearance of the ordinarily sharply defined fibrillar structure of the involved corneal stroma. The latter is independent of the yellowish color transmitted to the stroma by the contents of the anterior chamber.

The authors have found this sign to be useful in recognizing the very early stages of corneal bloodstaining. These biomicroscopic signs of corneal bloodstaining usually precede gross staining by only 24-36 hours. Surgical treatment in this early stage may prevent gross staining, and the cornea may clear more quickly. However, once grossly visible staining develops, many months may elapse before clearing is complete.

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