Hyphema is a pathological condition of the organ of vision, in which blood is detected in the anterior chamber of the eyes. Clinical manifestations are “fog” or “shroud” in front of the eyes, decreased visual acuity, photophobia. Diagnosis of hyphema is based on examination of the anterior parts of the eye, biomicroscopy, gonioscopy, visometry, tonometry, ultrasound B-scanning. Depending on the stage of the disease, combined conservative treatment with corticosteroids and mydriatics is indicated. Surgical intervention in hyphaema is reduced to washing the anterior chamber of the eye and performing a trabeculectomy.
Hyphema is an accumulation of blood and blood clots in the anterior chamber of the eye as a result of trauma, rupture of newly formed vessels or against the background of hematological diseases. The traumatic origin of the disease in males is three times more common than in females. Other etiological variants are equally common in ophthalmology. Patients after 40 years are more likely to develop hyphema. In infants, pathology develops very rarely against the background of shaking syndrome or congenital blood diseases. The disease is characterized by a complicated course with a tendency to progression. In the absence of adequate treatment, hyphema leads to complete blindness. More than 35% of cases have relapses on day 2-5.
Traumatic injuries of the eyeball play a key role in the development of hyphema. With a penetrating wound, the membranes are ruptured and the vessels are damaged, which leads to hemorrhage in the anterior chamber of the eye. Non-penetrating wounds due to blunt trauma are accompanied by an increase in intraocular pressure. A sharp increase in IOP provokes rupture of blood vessels and the inner membranes of the eyeball. Most often there is damage to the iris, ciliary body and choroid. Hemorrhages can develop during surgery during abdominal or laser surgery. The etiological factor is damage to the vascular plexuses of the iris or ciliary body. The cause of hemorrhage in the postoperative period is the instability of hemodynamics and thrombus.
In some cases, hyphema is a consequence of rupture of newly formed vessels of the eyeball. A low degree of differentiation leads to the formation of a thin and fragile vascular wall, which is unstable to an increase in intraocular or systemic arterial pressure. The process of neovascularization is characteristic of diabetes mellitus in the decompensation stage, malignant choroidal melanoma, iris rubeosis, pseudoglyoma and thrombosis of the central retinal vein. Hemorrhages in the anterior chamber of the eye are most susceptible to patients with a history of hematological diseases (hemophilia, sickle cell anemia, thrombocytopenic purpura, vasculitis, acute or chronic leukemia).
The clinical picture of hyphema depends on the volume of blood in the anterior chamber of the eye. With microgyphema, the disease has a latent course. Sometimes patients note slight discomfort, hyperemia is not characteristic. The first stage is characterized by the appearance of “fog” in front of the eyes. Patients can observe a narrow strip of red-brown color during self-examination. With a traumatic origin, photophobia and pain syndrome may develop. At the second and third stages, clinical manifestations increase: the blood level is noticeable at a distance, a veil appears before the eyes, vision decreases slightly. Neurological symptoms are added: “flies” in front of the eyes, headache, dizziness. Total, or “black”, hyphema is accompanied by complete loss of vision. In a number of patients, only light perception is preserved. Even after the treatment, a trace amount of shaped elements is determined in the cornea, which changes its color and negatively affects visual functions.
The accumulation of blood in the anterior chamber of the eye provokes an increase in intraocular pressure, which is a predictor of the development of secondary glaucoma. The long-term complications of hyphema include the formation of anterior synechiae on the periphery of the eyeball. The combination of increased IOP, vascular occlusion and contusion in traumatic hemorrhage leads to optic nerve atrophy. This pathology causes splitting of the ciliary muscle and displacement of the iris and lens posteriorly, as a result, the helmet channel narrows down to its complete blockade. These circumstances, as well as the mechanical pressure of the accumulated volume of blood, leads to a deepening of the angle limited in front by the cornea and sclera, in the back by the ciliary body and the iris, which underlies the recession of the angle of the anterior chamber of the eye.
Diagnosis of hyphema is based on the data of anamnesis, objective examination, results of biomicroscopy of the eye, gonioscopy, visometry, tonometry, ultrasound B-scan. In the anamnesis, most patients have traumatic damage to the eyeball, surgical interventions, blood diseases or eye pathologies, accompanied by increased angiogenesis processes. Upon objective examination, the microgyphema is not determined. To verify it, it is necessary to perform microscopy of the intraocular fluid, in which traces of shaped blood elements will be determined. At stage I of the disease, the anterior chamber of the eye is filled with blood by 1/3; at stage II – by 1/2; at stage III – by 3/4. Stage IV is characterized by filling the entire volume of the anterior chamber with a red-brown hemorrhagic fluid.
Biomicroscopy using a slit lamp determines the pool of circulating red blood cells in the fluid of the anterior chamber of the eye or whole blood. Other organic changes are detected as a result of trauma (subconjunctival hemorrhages, facodon, rupture of the iris sphincter, foreign bodies of the eye, etc.). Ultrasound B-scanning allows you to visualize signs of traumatic damage even with total hyphema and determine the source of bleeding.
Examination of the anterior chamber of the eye by gonioscopy is carried out no earlier than 21 days after hyphema relief. This study is necessary as a screening for early detection of complications (anterior synechiae, angle recession). Visometry is indicated for monitoring the function of vision after treatment. At stage I, II and with microgyphema, visual acuity is measured after the end of the course of therapy, at stage III, IV – 1 time per month. The tonometry method determines the level of IOP, which increases with the development of glaucoma. All patients are recommended to conduct a general blood test and coagulogram to exclude hyphema against the background of hematological diseases.
Microgyphema does not require special treatment. Conservative therapy at the I, II stages of the disease involves the local use of drops of corticosteroids (prednisone) and mydriatics (atropine). By inhibiting the processes of fibrinolysis, corticosteroids prevent the development of relapses. Aminocaproic acid, which is used systemically, has antifibrinolytic activity. Atropine prevents the formation of anterior synechiae, reduces the manifestations of photophobia, reduces the severity of accommodation spasm. With an increase in IOP, oral administration of carbonic anhydrase inhibitors (acetazolamide, dorzolamide) is recommended.
Surgical treatment of hyphema is carried out at the III, IV stages of the disease. To flush the anterior chamber of the eye, two parallel paracentesis are performed. A balanced crystalloid solution is poured into one of the holes, blood and formed blood clots are removed through the second. Performing a trabeculectomy improves blood outflow, leads to a decrease in IOP and eliminates the pupillary block. Obliteration of the postoperative fistula occurs independently.
Treatment of patients with sickle cell anemia in the anamnesis excludes the use of carbonic anhydrase inhibitors. Drugs of this group reduce the partial pressure of oxygen in the fluid of the anterior chamber, which leads to deformation of red blood cells. Deformed shaped elements lead to blockage of the outflow pathways of intraocular fluid, which provokes an increase in IOP.
Treatment of hyphema in most cases is carried out on an outpatient basis. Inpatient treatment is subject to a group of patients with high IOP values that are not amenable to drug correction, patients with blood pathologies and under the age of 3 years. Bed rest with the maximum possible restriction of motor activity is recommended. In bed, you should lie with the headboard raised by 40-50 degrees. During the day, it is necessary to wear a protective shield on the affected eye.
Prognosis and prevention
Specific measures for the prevention of hyphema have not been developed. Patients with a burdened history of blood diseases need to carry out timely monitoring of hematological parameters. All patients with diabetes mellitus and arterial hypertension are subject to dispensary observation by an ophthalmologist 2 times a year. Persons with oncological eye diseases are subject to a detailed examination by an ophthalmologist once every 3 months. Timely treatment provides a favorable prognosis for life and performance. A total decrease in visual acuity with further disability is possible in patients at stage III, IV with inadequate or delayed surgical intervention.