What is the role of surgery in the treatment of hyphema?

Updated: Jan 18, 2019
  • Author: David L Nash, MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Generally, medical management seems to produce the best visual results for patients with less than total hyphemas. Certainly, other causes of inflammation or bleeding should be ruled out, particularly when the history of trauma is questionable. [63]

For several reasons, surgical management is fraught with complication. [40] First, surgery is chosen for the most severe presentations of hyphema, thus selecting out the most difficult cases. Surgical intervention is rarely indicated for hyphemas that occupy less than one half of the anterior chamber; these lesser hyphemas (either primary or secondary) usually resolve spontaneously under any medical regimen and require no surgical intervention.

In 2 prospective series totaling 196 patients, no corneal bloodstaining or optic atrophy was noted in hyphemas of 50% or less. [6, 11] Corneal bloodstaining, with rare exceptions, only occurs in patients with hyphemas that are total at some time during their course. The results of surgical evacuation to improve secondary glaucoma in small hyphemas (75% or less) are disappointing. The ocular hypertension in these instances results more frequently from damage to the trabecular structures than from plugging by red cells and fibrin. Surgical evacuation in these instances may produce only temporary postsurgical hypotony, with a rapid return to preoperative intraocular pressure.

The authors believe that most hyphemas, including total hyphemas, should be medically treated for the first 4 days. Spontaneous resolution of the hyphema occurs quite rapidly during this period, and these cases have the best prognosis. In one series of 20 eyes with total hyphemas, 4 of these 20 eyes (20%) cleared sufficiently by day 4 to rule out surgery. [27] An additional 4 eyes resolved spontaneously on medical treatment over a longer period.

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