When is surgery indicated for 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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Surgical intervention is usually indicated on or after the fourth day. Overall, indications for surgical intervention are outlined below. [6, 27]

  • Four days since onset of total hyphema and the hyphema has not cleared
  • Microscopic corneal bloodstaining (at any time)
  • Total hyphema with intraocular pressures of 50 mm Hg or more for 4 days (to prevent optic atrophy)
  • Total hyphemas or hyphemas filling greater than 75% of the anterior chamber present for 6 days with pressures of 25 mm Hg or more (to prevent corneal bloodstaining)
  • Hyphemas filling greater than 50% of the anterior chamber retained longer than 8-9 days (to prevent peripheral anterior synechiae)
  • In patients with sickle cell trait or sickle cell disease who have hyphemas of any size that are associated with intraocular pressures of greater than 35 mm Hg for more than 24 hours

If intraocular pressure remains elevated at 50 mm Hg or more for 4 days, surgery should not be delayed. One study noted optic atrophy in 50% of patients with total hyphemas when surgery was delayed. Corneal bloodstaining occurred in 43% of patients. [64] A 2013 study of 138 pediatric traumatic hyphemas found an increased likelihood of required surgical intervention if patients presented with increased intraocular pressure. [3]

Patients with sickle cell hemoglobinopathies and even those with sickle cell trait require surgical intervention if intraocular pressure is not controlled within 24 hours. [6, 28] An interesting study of hyphema in rabbits measured partial oxygen pressure in the aqueous humor after injection of blood from a patient with sickle cell versus injection of an air or oxygen bubble with the blood from the patient. After 10 hours, the partial pressure of oxygen was 123.35 mm Hg in the blood plus air bubble group and 306.47 mm Hg in the blood plus oxygen group, compared to 78.45 mm Hg and 73.97 mm Hg for the placebo (no injection) and blood only injection groups, respectively. The authors recommended leaving an air or oxygen bubble in the anterior chamber after a washout in patients with sickle cell disease or trait. [65]

MomPremier et al described a two-needle, office-based technique for performing an air-fluid exchange (see image below) in several patients without sickle cell. [66] The authors of this article have not attempted this technique.

Air-fluid exchange two-needle technique: (a) Entry Air-fluid exchange two-needle technique: (a) Entry into the anterior chamber superiorly with gas-filled syringe. (b) After partial gas injection, entry into the deepened anterior chamber inferiorly with evacuation syringe, plunger removed. (c) Evacuation of hyphema with complete or near complete anterior chamber fluid-gas exchange. (d) Inferior needle is removed while superior gas-filled syringe is used to equilibrate intraocular pressure. Courtesy of Hindawi Publishing Corp under Creative Commons Attribution License [MomPremier M, Sadhwani D, Shaikh S. An Office-Based Procedure for Hyphema Treatment. Case Reports in Ophthalmological Medicine. Vol 2015; Article 321076; http://dx.doi.org/10.1155/2015/321076].

Surgery for patients with hyphema should be cautiously approached. In 2 series involving 196 patients, surgery was performed in only 14 patients (7.1%). [6, 11] Risks of surgery include damage to the corneal endothelium, the lens, and/or the iris; prolapse of the intraocular contents; rebleeding; and increased synechiae formation. Except for patients with sickle cell trait, no patients in these series required surgery if the hyphema occupied less than 50% of the anterior chamber. Total hyphema evacuation by vitrectomy instrumentation, peripheral iridectomy, and trabeculectomy has been recommended.

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