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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, September 29, 2015


Boring EM - Posted by Paul Young
Medical Concept: Hyphema

"Management and Disposition
The emergency department management of hyphema centers on control of any ongoing bleeding within the eye, prevention of any subsequent bleeding and the anticipation and treatment of hyphema complications. A number of treatment modalities for the treatment of hyphema have been traditionally described, however there is often little evidence that these measures improve final visual acuity [7].
Use of an eye shield is recommended for prevention of any potential further trauma to eye. Elevation of the head of the bed to 35-40 degrees helps to promote settling of blood inferiorly and prevent occlusion of the trabecular meshwork by red blood cells [3]. In the past, patients were admitted and put on bed rest to minimize the risk of rebleeding, however there is significant controversy regarding the benefits of this intervention [7],. Most patients are now counseled to refrain from strenuous activity and managed as outpatients, with frequent follow-up examinations.
Topical anti-fibrinolytic drugs including aminocaproic and transexamic acid have been used in hyphemas and help to reduce the occurrence of rebleeding[8]. However there is no definite evidence suggesting they help to improve final visual acuity[7] and these are now rarely used.
A cycloplegic, such as atropine 1%, is often used with the intent of preventing pupillary movement thus limiting further movement of torn iris vessels and promoting tamponade [6]. The agent of choice is generally best directed by the consultant ophthalmologist, as certain eye drops such as atropine have a long duration of action.
Pain management is best accomplished by acetaminophen. The use of platelet inhibiting drugs is not recommended.
Recognition and management of raised intraocular pressure is of paramount importance as bleeding may block the trabecular meshwork of the eye and prevent the normal drainage of aqueous humor leading to secondary glaucoma. The normal intraocular pressure (IOP) of the eye is between 10 and 20 mmHg of mercury. Elevations above this range, especially above 35mmhg, are concerning and can lead to damage to the optic nerve. Treatment of raised IOP is usually accomplished initially with the use of a topical β-blocker such as 0.5% timolol, which acts to decrease the production of aqueous humour. Topical α2-agonist therapy with an agent such as brimonidine can also be used. Acetazolamide, a carbonic anhydrase inhibitor, also decreases production of aqueous humor at a dose of 500mg IV or PO. Hyperosmolar therapy with mannitol reduces total volume of aqueous humour through the generation of an osmotic gradient, drawing fluid into the intravascular space. Dosing is at 1 to 2 g/kg IV [3].
All patients with hyphema deserve prompt consultation by an ophthalmologist, as some complications may not be apparent until several days after the injury. Rebleeding commonly presents within the first few days following the initial injury as initial clotting retracts [3], and is associated with a worse prognosis. A hyphema may also lead to the development of membranous anterior or posterior synechiae secondary to the inflammatory process in the eye, whereby the iris may become adherent to the cornea or the lens respectively. Corneal staining by blood and angle recession glaucoma are other potential complications."