Abstract
Aim
To review the management strategy of
non-penetrating traumatic hyphema in
ophthalmology department of HMC (Hamad Medical
Corporation) and compare it with other
international approaches.
Methods
This is a retrospective study for evaluating the
management of non-penetrating traumatic hyphema
in the Ophthalmology Department of Hamad Medical
Corporation. Records of 83 patients over
the period between January 1999 and May 2003
were studied for various criteria including:
demographic factors; causes; severity and type
of hyphema; visual and intraocular pressure
outcome; and application and outcome of medical
and surgical treatment. Patients' criteria
and treatment policy was compared with other
studies.
Main Outcome Measures: Visual acuity as defined according to
the WHO system
Results
Total of 83 patients; 76% males and 24% females,
their average age was 24.4 years. The
majority had hyphema due to work trauma 45.8%,
76% recovered 6/12 or better vision within one
month, 14% developed glaucoma, 2.4% complicated
by corneal blood staining. Mydriatics were
used in 65%, 5 % had re-bleeding. All the
patients were treated as inpatients, only one
case required surgical intervention for
uncontrolled IOP and early corneal staining.
Conclusion
Dependent on the findings of our study and other
studies, we rationalized alterations to be
concerned according to Qatar locality, however,
the general outcome of traumatic hyphema in our
department was not bad.
Key Words
Traumatic hyphema, visual outcome, glaucoma, corneal bloodstaining,
associated injuries, re-bleeding,
antifibrinolyics, inpatient and medical
treatment, surgical intervention.
Introduction
The incidence and distribution of traumatic
hyphema varies among different countries.
Treatment suggestions in the texts vary
considerably among miscellaneous published
articles; this lack of uniformly conventional
strategy possibly reflects the different
characteristics of this eye problem in the
patients studied.
A survey had been done for the ophthalmologist
about the management of traumatic Hyphema in
Texas; results of this survey emphasize the lack
of consensus surrounding treatment of traumatic
hyphema(1).
The lack of an ideal therapeutic program, the potential for secondary
hemorrhage, and the secondary onset of glaucoma,
all threaten to transform an eye with an
initially good visual prognosis into a complex
therapeutic problem with poor visual result (2)
.
What are the preferred therapeutic options? Outpatient treatment or
hospitalization? Should the involved eye be
shielded? What are the indications for
topical medication? What are the
indications for antifibrinolytics, aminocaproic
acid (ACA)? When and how should surgical
intervention be applied? The answer for
these questions is variable but usually not
paradoxical among different centers. The
therapeutic preferences in the ophophthalmology
department at HMC was variable as there was no
predetermined fixed protocol undertaken by all
staff for the management of hyphema patients.
The intention of this study is to assess the
current hyphema management strategy and to
adjust it according to our circumstances in
Qatar.
Methods & Subjects
This study is a retrospective study about the
traumatic hyphema patients of the previous 4
years (January 1999-May 2003) conducted at the
department of Ophthalmology at HMC. Charts
of all patients have been analyzed in
retrospect.
Patients with a diagnosis of spontaneous hyphema
or ruptured globe were excluded.
Data obtained from patients' records
include: year of admission, all ages were, sex,
nationality, mechanism of injury, duration of
hospitalization, laterality, initial and final
IOPs (intraocular pressure) and visual acuities.
The visual acuity (VA) has been
classified according to the WHO (World Health
Organization) table1(3) . The hyphema was
classified into: clotted blood, diffuse blood,
or mixed and its size graded into four grades
depending on the extent of the anterior chamber
filling with blood: (4)
= Grade I: Less than one third of
anterior chamber
= Grade II: One third to one half of
anterior chamber
= Grade III: One half to nearly total
= Grade IV Total (eight ball)
TABLE
1: WORLD HEALTH ORGANIZATION
CLASSIFICATION OF VISUAL ACUITY
The records were also reviewed for histories of
systemic and ocular diseases, drugs especially
aspirin, gonioscopic and optic nerve appearance,
and treatment approaches. Patients'
criteria and management were compared with those
from other studies.
The data was entered into a computer and
analyzed with SPSS windows (version 9) using
tests of significance (Chi-square, Fischer's
exact and T-tests) for statistical analysis.
Library Medline and Internet were the
main databases used for the literature search
conducted in preparation for this article.
Results
Records of 83 patients with non-penetrating
traumatic hyphema were analyzed.
13(15.7%) in 1999, 14(16.9%) in 2000,
24(28.9%) in 2001, 22(26.5%) in 2002 and 10(12%)
in the first 5 months of 2003.
The average age was 24.4 years, 63(76%) males
and 20 (24%) females (Table 2) 40 (48.2%) had
right eye and 43 (51.8%) had left eye hyphema.
TABLE
2: HYPHEMA GRADING AND CHARACTERISTIC
DISTRIBUTED ACCORDING TO THE SEX
The kind of injury and trauma were variable;
38(45.8%) at work, 28(33.7%) during playing or
athletic activities, 11(13.3%) occurred in
street assaults and the minority due to other
causes such as accidental trauma at home or a
fall on ground.
The majority of the patients, 73(88%),
were healthy before the traumatic hyphema and
had no diseases. 3(3.6%) had history of ocular
disease and 7(8.4%) had systemic diseases.
Table 3, Most of the patients recovered normal or near normal visual
acuity over a one month period from the time of
trauma 60(76%), 43 of them had grade I hyphema,
and by using Chi-Square test, the visual
recovery was proved to correlate significantly
with the severity of initial hyphema P<
0.005. The smaller the hyphema, the better
the visual outcome.
TABLE
3: THE VISUAL AND IOP OUTCOME IN RELATION
TO HYPHEMA GRADES
|
*Final V &IOP = VA & IOP one
month after trauma
|
A minority developed persistent high IOP 11(14%); 3 of them couldnÕt be
controlled by medication. The difference
between those who developed pathological rise of
IOP and the group who continued to have normal
IOP in correlation to the severity of hyphema
was statistically significant by Chi-Square
test, P< 0.0005.
Table (4), Synechiae were seen in 1/5th of the
cases and rebleeding occurred in 4(5%) and both
were not correlated with significance to the
grade of hyphema
( low
or high grades), as t-test statistics has showed
the two tailed probability > 0.05 in both.
TABLE
4: THE INCIDENCE OF SYNECHIAE AND
REBLEEDING ACCORDING TO
THE LEVEL OF INITIAL HYPHEMA
Table 5. The anterior and posterior segment injuries were found in
39(47%) and 17(20%) respectively and both were
found in 4(4.8%). The most encountered
associated traumatic complications were cataract
6(7.2%) and vitreous hemorrhage 4(4.8%),
however, 23(28%) had no ocular injuries apart
from hyphema.
TABLE
5: INCIDENCE AND EFFECT OF ASSOCIATED
INJURIES ON VISUAL OUTCOME
ONE MONTH AFTER TRAUMA
|
*Final VA= VA one month after trauma
|
Table 6. 41(49%) were treated with patching for one or both eyes and
there was no significant difference between
using patching and not using on the rate of
rebleeding, by Fisher's exact test, P>
0.0005.
TABLE
6: REBLEEDING INCIDENCE WITH TREATMENT
STRATEGIES
The difference between the average rebleeding rate in the specifically
medically treated group by mydriatics 54 (65%),
and the rate in the untreated group, 29 (35%),
was not statistically significant, with a
probability of >0.0005 by Chi Square Test,
Yates Corrected Chi Square Test and Fisher's
Exact Test.
Discussion
In one
study, the Mean Annual Incidence of hyphema was
approximately 17 per 100,000 populations(5).
Population of Qatar is about 600,000 and
the Annual Incidence of Traumatic hyphema is
approximately 3 per 100,000 populations.
The main cause of injury in our department was a result of work related
injuries 45.8% this might be explained on the
basis of increasing construction during the last
few years in Qatar. The figure is diverse
in other studies. In one study 44% of
traumatic hyphema occurred on street (during
assaults), and 12% occurred at work or during
athletics (6). In an other study, sports
injuries from soccer, hockey, baseball, and
basketball accounted for up to 60% of traumatic
hyphema(2).
Most patients had simple hyphema; the majority had grade I (61.3%), mixed
hyphema (clotted + diffuse blood) in 54(65%).
The majority of patients were males (76%) (Table 2), this was probably because in our study the
major cause of traumatic hyphema was related to
work injury.
The males are more likely to have trauma
than females (7).
Patients with initially larger hyphema tended to have poor visual
acuities(8).
Approximately 80% of hyphema patients with less than one-third filling of
the anterior chamber regain visual acuity of
20/40(6/12) or better, 60% of those with greater
than half and less than total hyphema regain
20/40 or better. Of those with an initial
total hyphema, only 35% have good visual
results(2).
VA was not checked in 4 (5%) patients because they were not cooperative
or were illiterate. 60(76%) recovered 6/12, or
better, vision one month after the trauma.
The smaller the hyphema the better visual
outcome would be (Table 3).
Approximately one-third of all hyphema patients exhibit increased IOP
(9). It is generally true that the larger
the hyphema volume, the greater the likelihood
of increased IOP(12).
Secondary hemorrhage is often associated with increased IOP(6). The
incidence of late onset glaucoma in eyes with a
history of traumatic hyphema ranges from 0-20%
(10).
Intraocular pressure was measured in all patients except 4 (5%) who were
not cooperative for Aplanation Tonometery;
11(14%) developed glaucoma within month after
trauma (Table 3); 8 of them had been controlled
with antiglaucoma drugs and 3 had persistent IOP
in spite of treatment. Studies estimate
that corneal bloodstaining occurs in
approximately 5% of patients with traumatic
hyphema (8,11) ; 2.4% of our patients were
complicated by corneal bloodstaining.
The synechiae formation was noticed in 16(19.3%) patients, 84 % of them
had grades I or II hyphemas, P >0.05 by
T-test (Table 4). This could be justified
by the fact that many cases had missed synechiae
diagnosis because not all patients had been
examined for PAS by gonioscopy and so the
synechiae formation was underestimated.
The incidence of peripheral anterior
synechiae (PAS) increased with the size and
duration of visible hyphema greater than 8 days.
Ssynechiae occur more frequently in patients who
have had surgical evacuation of the hyphema3.
We found no significant correlation between
synechiae and severity of hyphema as other
studies did (2 , 3).
Secondary hemorrhage occurred in 4 (5%) patients (table 4). It was
higher in some studies where it occurred in
approximately 22% of all hyphema patients with a
range between 7% and 38% 12, and of smaller
incidence in other studies 3.5% 13.
Only one case developed optic atrophy; and it was preceded by period of
transient high IOP (Table 4).
Non-glaucomatous optic atrophy in hyphema
patients may be due to either the initial trauma
or to transient periods of markedly elevated IOP
(3).
Anterior segment injuries associated with poor prognosis include corneal
blood staining, iridodialysis, lens subluxation,
cataract, and traumatic mydriasis(14) .
Nevertheless, the visual outcome for patients
with other associated injuries was quite good;
60 (72%) of them had recovered normal vision by
6/12(20/40) or better, over a one month period,
(Table 5), possibly because the trauma was not
severe enough to cause damaging injuries and/ or
most patients had no history of previous ocular
and systemic disease that could make the eye
more vulnerable to complications, even with
trivial traumas.
The associated anterior segment and posterior
segment injury with the traumatic hyphema had
occurred in 39(47%) and 17(20%) patients
respectively (Table 5).
Management
The overall management for traumatic hyphema was directed toward minimizing secondary hemorrhage and
reducing the
incidence of secondary glaucoma.
Inpatient Versus
Outpatient Treatment
Non-controlled studies showed no significant
differences in rebleeding rates and clinical
outcomes in patients treated at home or in
hospital. (15)
All patients were treated as inpatients and the period of hospitalization
ranged from 3 to 15 days, the mean hospital stay
was 6.4 days.
We prefer to admit the patient because
there is increased risk for re-bleeding as an
outpatient, even in small hyphemas; as was found
by Rahmani(15) whose re-bleeding occurred in 15%
of microscopic hyphema.
Advantages of hospitalization include ease of follow up examination,
confirmation of medical compliance, and possible
earlier detection of complications. The
cost is the overriding disadvantage (14).
Outpatient care has the advantage of being the
usual preference of patients and their families.
(7)
Bed Rest and Eye Patching
(49%)41 were patched for one or both
eyes. Secondary hemorrhage had been reported in
(4.8%)2/41 of patched patients, while it was (4.7%)
2/42 among non-patched (Table 6). It has been demonstrated that
binocular occlusion has no advantage over
monocular, and the former is hazardous
psychologically.
Furthermore, patching may promote
bacterial growth by raising the temperature in
the conjunctival sac (12).
Likewise, as seen in more recent studies,
patching does not seem to have any effect at all
on the outcome.
Read and Goldberg reported the incidence of
rebleeding to be 18% among those treated with
bed rest, bilateral patching, elevation of the
bed (300), and sedation as opposed to 25% among
those treated with quiet ambulation, patching of
the traumatized eye only, elevation of the bed
(450), and no sedation. Differences between the
groups were not statistically significant 1.
Corticosteroids
Yasuna postulated that steroid induced reduction
of uveitis might decrease the tendency of
congested uvea to rebleed (16).
Topical corticosteroids were applied to all
patients. Systemic steroids (prednisolone
1mg/kg) had been used in 3 patients only,
however, none of them had rebleeding.
Mydriatics
Rakusin examined whether the use of Mydriatics,
miotics, or both influence the outcome of
traumatic hyphema.
He found no significant difference in the
incidence of rebleeding, in the final visual
acuity, in the rate of clot absorption, or in
the incidence of complications regardless of
whether the patient was using a Mydriatic,
miotic, neither, or both. (17)
Atropine 1% drops were mostly used as single
dose at the time of presentation, so as to
immobilize
the pupil and to make fundus examination easier
before development of other traumatic
complication which could obscure retinal
viewing. The potential risk for rebleeding with
the use of early mydriasis was proved not
statistically significant by Corrected
Chi Square Test and Fisher's Exact Test, (Table
6).
Surgical Management
Surgical intervention was required for one case only because of
uncontrolled high IOP with early corneal
staining. Surgical
management is only used in approximately 5% to
7.2% of hyphemas(11). Most hyphemas
including total hyphema should be treated
medically for the first 4 days as spontaneous
resolution of the hyphema occurs quite rapidly
during this period and these cases have the best
prognosis.(12)
SUGGESTED
PROTOCOL FOR TRAUMATIC HYPHEMA MANAGEMENT IN
HMC
OPHTHALMOLOGY DEPARTMENT
|
CRAO = Central Retinal Artery Occlusion
|
Conclusions
The results indicate that our present treatment may be moderately good
but it needs further modifications so as to have
optimum outcome.
Recommendations
-
All workers at risk of eye
trauma ought to wear protective goggles.
-
In accordance with other
studies, which have proved that
antifibrinolyics have a minimal role in
reducing secondary bleeding and might cause
serious side effects (7,16,18) we advise not
to use them as part of the treatment
strategy for hyphema.
-
Reliant on the observations of
the previously reported studies and our
study findings, we can justify some
modifications to apply the
following protocol for the management
of traumatic hyphema.
References
