Traumatic : A Review of Experience at the Medical College of Virginia During the Past Decade

WALTER J. GEERAETS, CHING-HUNG LIU, AND DuPONT GUERRY, Ill Department of , Medical College of Virginia, Richmond

Hyphema (hemorrhage into the complication. Thygeson and Beard anterior chamber of the eye), as (1952) reported a high incidence the result of blunt to the (38%) of secondary hemorrhage. eye, carries a potential danger of In the 13 cases with secondary visual loss if not properly treated. hemorrhage, developed This review of cases seen in the in seven. None of the patients that MCV Hospitals over the last dec­ had only a single hemorrhage de­ ade lists some of the complications veloped glaucoma. In five of the and stresses some of the important seven cases of secondary glau­ factors in the management. coma, vision was reduced to mere Traumatic hyphema from non­ light perception, and enucleation perforating was not con­ had to be performed in several of sidered a specific problem until the those. last decade, in spite of Cordes' In the last decade various at­ ( 1932) warning that ocular con­ tempts have been made to prevent tusion, even if complicated only prolonged or repeated hemorrhages by hyphema, must be regarded as and to enhance blood absorption a potentially serious condition. A from the anterior chamber. Based little more than 10 years later, upon experiments in rabbits, Bene­ Rychener ( 1944) emphasized that dict and Hollenhorst ( 1953) the hazardous results from secon­ warned against the use of cortisone dary hemorrhage could in most in­ in treating traumatic hyphema, as stances be avoided only by early it reduced the rate of blood absorp­ and effective treatment, for at­ tion from the anterior chamber. tempts to treat complications al­ Wilson et al. ( 1954) advocated ready present when the patient early air injection. Wilkinson (1956) came for treatment were frequently and Loring (1958) favored medical unsuccessful. This author reported management first, followed by sur­ gratifying results in the use of gery where indicated. Goldberg miotics and simple paracentesis in ( 1960) used conjugated estrogen. treating 13 cases of traumatic hy­ Glaser ( 1960) applied diathermy phema complicated by increased coagulation as a prophylatic meas­ . Laughlin ure. Scheie (1963) reported good (1948) showed that eyes with re­ results from irrigation of the an­ peated hemorrhages had a poor terior chamber with fibrinolysin to prognosis. Lock (1950) pointed dissolve blood clots. out that although most cases of The use of miotics or mydriatics traumatic hyphema subsided with­ for treatment of traumatic hyphema out further incident, secondary is still debated. Mydriatics, how­ glaucoma was always a possible ever, appear to be used more

20 MCV QUARTERLY 3(1): 20·25, 1967 W. J . GEERAETS, C. H. LIU AND D. GUERRY often. Adequate bed rest has al­ Age ways been stressed as an important TABLE 3 factor in preventing secondary The ages ranged from 2 to 67, Month Incidence of 198 Cases of Traumatic Hyphema hemorrhage. Cordes ( 1932) con­ but 115 patients ( 58 % ) were be­ sidered inadequate physical rest low 15 (table 1) . No. of the most important cause for sec­ Month Cases ondary hemorrhage, and Kronfeld Sex a nd Race (table 2) January 12 (1951) noted that, in his experi­ February 13 ence, treatment with drugs was less The majority (87% ) of patients March 14 important than complete bed rest. were male. Slightly more than one­ April 13 May 32 Smith (1952) and Kreman and third ( 41 % ) were Caucasian. June 21 Hagigh ( 1959) showed a greater Since there is a preponderance of Negro patients in our clinic popu­ July 13 incidence of secondary hemorrhage August 25 lation as a whole, the significance in ambulatory patients than in September 16 those at bed rest. Glaser (1964), of this racial incidence is uncer­ October 17 in a poll of ophthalmologists, tain. There were no cases of bi­ November 7 found that most of them consid­ lateral hyphema. December 15 ered adequate bed rest the most important single factor in prevent­ Incidence by Season and Month ing complications. (table 3)

In approximately half of the cases, trauma occurred during the four summer months, May through Description of Patients in This August. Approximately half of the Re view injuries from BB shot happened in December and January. The charts of patients admitted to the MCV Hospitals from 1954 through 1964 with a diagnosis of traumatic hyphema from non­ TABLE 1 TABLE 4 perforating injuries were reviewed. Age Incidence of 198 Cases of Trau­ Objects Causing Contusion of 198 Among 4,798 patients admitted to matic Hyphema Cases of Traumatic Hyphema the Eye Service during that period, there were 209 cases ( 4. 3 % ) of No. of Objects Cases Age Patients traumatic hyphema. After exclud­ Rock 44 2- 5 20 ing inadequate records, 198 cases BB pellet 17 6-10 50 Struck, fight, blackjack 16 remained. These cases were arbi­ 11- 15 45 Wood, tree branch 15 trarily classified into two cate­ 16-20 11 Stick 14 gories : 21-30 30 Various working tools 12 1) Those seen within 24 hours 31-40 24 Baseball 11 41 - 50 10 after injury. There were 152 in this Various household objects 10 51-67 8 group. Biomicroscopic examination Fall and hit 8 revealed hyphema in five patients; Elbow, hand, fist (at game) 8 135 had hyphema affecting less Bullet, shell 6 than three-fourths of the anterior Various fruits 6 chamber, and 12 had involvement Automobile accident 5 of more than three-fourths of the Kicked in eye 3 chamber. Arrow 3 Snowball 3 2) Those seen later than 24 Marble 2 hours after injury (two to six days). Toy gun 2 There were 46 in this group. Most TABLE 2 Handball 2 of these patients came late simply Race, Sex, and Eye Incidences of 198 Softball 2 because of negligence. There were Cases of Traumatic Hyphcma Plastic ball 2 28 with hyphema of less than three­ Fishing rod, golfball 2 fourths, and 18 with hyphema of Race Sex Eye Shuttlecock 1 over three-fourths of the anterior NW MF OD OS Oyster shell 1 chamber. 140 58 175 23 88 110 Unknown 3

21 TRAUMATIC HYPHEMA

Causes of Hyphema (table 4) TABLE 5 Associated Ocular Lesions in 198 Cases of Traumatic Hyphema Of various objects causing con­ Cases seen Cases seen tusion, rock was by far the most Lesions within 24 hours after 24 hours Total common ( 44 cases), followed by BB pellet; industrial accidents were Fracture of orbital rim 3 3 rarely the cause for hyphema. Lid lesions 40 7 47 Subconjunctival hemorrhage 35 5 40 ! tear 8 8 Associated Ocular Lesions Corneal abrasion 57 3 60 (table 5) tear / rupture of sphincter 4 1 5 15 15 These were often not detected Iridoplegia 16 1 17 at the time of admission, but were Traumatic iritis 6 9 15 found when the hyphema cleared Traumatic 10 4 14 and the general condition of the Subluxation of 5 5 eye permitted a thorough examina­ 12 2 14 tion. In the 46 patients seen two Retinal hemorrhage, edema, tear 18 4 22 Macular lesions 5 5 10 to six days after injury, only three Choroidal rupture 4 4 showed evidence of corneal abra­ Severance of O.U. 1 1 sion. There were 18 cases of sec­ 1 1 ondary glaucoma among these 46 Secondary glaucoma on admission 5 18 23 patients at the time the patient Secondary glaucoma later 5 5 came for treatment. Pain undoubt­ edly caused these patients to seek medical aid. Traumatic cataract and dislocation of the lens oc­ curred in 19 (9.6% ) of the 198 cases. Retinal and macular lesions were found in 32 eyes (16% ) .

Complications

Table 6 lists the incidence of secondary hemorrhage in our se­ ries, along with the experience of others. Among 152 cases seen within 24 hours of injury, only 10 ( 6.6% ) developed secondary hem­ TABLE 6 orrhages. Gregersen (1962) re­ Incidence of Secondary Hemorrhage ported an incidence of secondary hemorrhage of 5.5% in a series of 2. Glaucoma associated 200 cases of traumatic hyphema. 1. Secondary with secondary Most secondary hemorrhages in Author Year (%) hemorrhage (% of 1) No. Cases hemorrhage our series occurred about the third Laughlin 1948 49 37 day after injury, which is in agree­ Thygeson 1952 34 38 54 ment with other reports (Greger­ Smith 1952 27 22 sen, 1962; Henry, 1960; Kushner, Wilson 1954 27 7 1959; Loring, 1958; Shea, 1957; Shea 1957 113 14 25 Wilson et al., 1954; T hygeson and Loring 1958 56 30 59 Beard, 1952). Kushner 1959 100 16 38 Kreman 1959 20 35 71 Table 7 gives the course of the 34 21 86 10 cases of secondary hemorrhage Henry 1960 204 17 51 in our series. It occurred in eyes Goldberg 1960 63 19 83 with varying degrees of hyphema Gregersen 1962 200 6 46 treated by different methods, and This series 1966 152 7 40 affected all age groups. Once sec­ ondary hemorrhage occurred, the

22 W . J. GEERAETS, C. H. LI U AND D. GUERRY

TABLE 7 Course of Illness in 10 Patients with Secondary Hemorrhage (Admitted 24 Hr after Injury) Patient Severity of Day of 2nd I No. Age Sex Race hyphema Treatment hemorrhage Later complications Final results - - --- 1 59 M N Less than 3 / 4 D, S, P * 10th Corneal staining 20/ 200 anterior chamber 2 21 M N D, S, * Chymar 4th Secondary glaucoma Evisceration 3 30 F N Air injection 3rd Secondary glaucoma, Enucleation corneal staining 4 13 M N D, P* 2nd Secondary glaucoma Hand movement (H.M.) 5 11 M N D, S, P* 3rd Secondary glaucoma, Aphakic correction, posterior synechiae, 20/ 50 , postop. 6 39 M N Bed rest only 2nd Count Fingers (C.F.) 7 30 M N S, P* 2nd Failed to follow 8 9 M w Bed rest only 3rd Failed to follow 9 27 M N Over 3/ 4 Bed rest only 3rd Vitreous hemorrhage Unknown anterior chamber 10 13 M N D, S, P * 7th Iris atrophy, H.M. traumatic cataract

* D = Diamox; S = Steroid (local); P = Premarin

prognosis was poor; six of the 10 cases resulted in blindness. Two TABLE 8 enucleations a re included. The on­ Resorption Time of Traumatic Hyphema in 121 Patients set was most frequently on the Resorption time (days) 1 2 3 4 5 6 7 8 9 10 11 12 third day after injury. No. of cases 5 28 18 16 13 11 17 7 6 1 1 1 In our series there were 23 (11.6%) patients who had secon­ dary glaucoma at admission. Five of these 23 were patients seen within 24 hours after injury. Of TABLE 9 those five, three regained 20/ 30 Resorption Time in 12 Patients vision or better, one suffered from Treated by Bed Rest Only secondary hemorrhage and subse­ Resorption time (days) 1 2 3 4 5 quent corneal staining with re­ No. of cases 1 3 4 3 1 sultant vision of 20/ 200, and one was discharged against advice. The other 18 were patients seen from two to six days after injury. The outcome of these 18 cases was as TABLE 10 follows: seven had 30/ 200 or less, Data on Four Patients Requiring Enucleation four had from 20/ 100 to 20/50, Age Sex Race Method of treatment Reason for enucleation six improved to 20/ 40 or better, --- - and one failed to return for fol­ 30 F N Air injection day of admission Painful glaucoma following sec- low-up. These results suggest that ondary hemorrhage glaucoma occurring soon after in­ 21 M N Diamox, local steroid Painful glaucoma following sec- ondary hemorrhage (bullet wound, jury has a better prognosis than severance of optical nerve O.U.) that occurring later than 24 hours 32 M N Extracapsular extraction of Panophthalmitis after the injury or after a secon­ associated dislocated lens, dary hemorrhage, which may have I same day developed before the patient's ad­ 4 F N Paracentesis and irrigation Panophthalmitis mission. I

23 TRAUMATIC HYPHEMA

There were six cases of blood ing steroids, on the resorption rate Management staining of the in our series. of traumatic hyphema will be pre­ Two occurred after secondary sented separately. Our management of traumatic hemorrhage, associated with sec­ Of the four patients who had hyphema has consisted in: 1) bed ondary glaucoma in the group seen to have enucleation, three had un­ rest with bathroom privileges (pa­ within 24 hours after injury, and dergone surgical treatment on the rents have been allowed to stay four occurred in eyes with secon­ day after injury (table 10). with their sick children); 2) eleva­ dary glaucoma in the group seen tion of the patient's head about later than 24 hours after injury. Visual Acuity 30° to 45°; 3) black eye shield for Intraocular , thus, the injured eye (stenopaic patch to seemed to be a precipitating factor The prognosis of visual acuity the normal fellow eye in special for blood staining of the cornea. is determined by the extent of cases) ; 4) firm (Wheeler) eye In evaluating the resorption time damage to the eye at the time of patch for corneal abrasions; and of hyphema, only those patients injury plus ensuing complications. 5) sedatives and analgesics. Drugs were included who: 1) were seen There were 130 patients on whom frequently used, either singly or within 24 hours; 2) had no sec­ data on visual acuity were avail­ combined, have included Diamox ondary hemorrhage; 3) were able. The results are tabulated in ( acetazolamide), Premarin ( conju­ treated medically only; and 4) de­ table 11. The causes of visual loss gated estrogens), and local steroids. veloped no glaucoma. There were for these patients were mainly at­ We have not prescribed Diamox 121 who fulfilled these criteria. tributable to associated ocular le­ routinely or prophylactically, but The average time of resorption was sions (table 5). However, if there only when the intraocular tension 4.6 days, with a range from one to was no serious associated ocular was elevated. If the elevated ten­ 12 days. In 105 (86.8% ) of the miury and no secondary hemor­ sion could not be controlled with cases, resorption occurred within rhage, even those patients with this drug, oral glycerol ( 30 cc in one week (table 8). In these 121 total, or nearly total, hyphema orange juice one or two times daily cases, there were 12 patients seen within 24 hours after injury for several days as indicated) or treated by bed rest only. Their av­ recovered good vision. The degree intravenous mannitol ( 10 % solu­ erage time of hyphema resorption of the initial hyphema, therefore, tion, 50 to 100 mg within 24 was three days (table 9) . The in­ may not necessarily be the only hours) was given. In some pa­ fluence of different drugs, includ- guide to prognosis of visual acuity. tients, the intraocular pressure could not be lowered by any con­ servative treatment, and here para­ centesis of the cornea with daily reopening of the incision was help­ ful. TABLE 11 Premarin was given in a few in­ Vision in 130 Patients with Traumatic Hyphema stances, although we are not aware of a controlled study of the effect Hyphema less than of this drug in this condition. 3 / 4 anterior Hyphema over 3/ 4 Visual Acuity chamber anterior chamber Total Mydriatics and miotics are not given since they may precipitate after after recurrence of . When sur­ within 24 hr 24 hr within 24 hr 24 hr gery must be performed, it should 20 / 20 or over 22 2 1 4 29 be as simple and atraumatic as 20/25 6 1 7 possible. Simple paracentesis of 20/30 14 3 3 20 the cornea with daily reopening of 20/ 40 12 4 2 1 19 the incision may be all that is 20/50 10 1 1 1 13 needed to carry the patient over 20/60 to 20/ 70 3 1 4 the phase when high tension can­ 20/100 3 2 1 6 20/200 to 20 / 400 7 2 2 1 12 not be controlled by conservative Count fingers, hand 7 3 1 3 14 measures. In certain instances gen­ movement tle irrigation of the anterior cham­ Light perception only 1 1 2 ber with normal saline solution or Enucleation 3 1 4 with fibrinolysin, as described by Undetermined 52 10 3 3 68 Horven (1962) have been bene­ Total 140 27 12 19 198 ficial. Mechanical extraction of a blood clot by forceps is always

24 W. J. GEERAETS, C. H. LIU AND D. GUERRY contraindicated, since such a pro­ Initial hyphemas were generally KRONFELD, P. C. Ophthalmologic cedure may lead to serious compli­ absorbed within a week. The aver­ urgencies and emergencies. Rocky cations. age hyphema resorption time was Mountain Med. J. 48: 511-513, Careful ocular examination is 4.6 days. 1951. important in all patients. If possi­ Of 130 recorded final visual acu­ KusHNER, A. G. Traumatic hyphema. ble, it should be done at the time ities, 75 (57% ) were 20/ 40 or Surv. Ophthalmol. 4: 2-19, 1959. of admission, and again during the better, 23 ( 17 .8 % ) were from LAUGHLIN, R. C. Anterior chamber course of hospitalization, for asso­ 20/ 30 to 20/ 100, and 32 (24.6% ) hemorrhage in nonperforating in­ ciated ocular lesions requiring were 20/ 200 or worse (including juries. Trans. Pacific Coast Oto­ treatment are common. total blindness). The prognostic laryngol.-Ophthalmol. Soc. 29: The relatively small number of factors which determine visual out­ 133- 140, 1948. cases in which there was surgical come in hyphema include the as­ LocK, J. A. N. Complication of trau­ matic hyphaema. Brit. J. Ophthal­ intervention ( 14 cases, of which sociated lesions sustained by the mol. 34 : 193, 1950. three later had enucleations) re­ eye at the time of injury, as well as LORING, M. J. Traumatic hyphema. flects the prevailing opinion that later complications, with secondary Am. J. Ophthalmol. 46: 873-880, hemorrhage being probably the traumatic hyphema from non-per­ 1958. forating injury for the most part most important single factor. RYCHENER, R. 0 . The management of is best treated conservatively. traumatic hyphema. J. Am. Med. Assoc. 126: 763-765, 1944. Summary SCHEIE, H. G., B. J. ASHLEY, JR., AND References D. T. BURNS. Treatment of total Early treatment and strict bed hyphema with fibrinolysin. Arch. rest for traumatic hyphema has re­ BENEDICT, W. H., AND R. W. HoL­ Ophthalmol. 69 : 147-153, 1963. sulted in a reduced incidence of LENHORST. The influence of corti­ SHEA, M. Traumatic hyphaema in secondary hemorrhage over the sone on the rate of blood absorp­ children. A review of 113 cases. tion from the eye. Am. J. Ophthal­ last decade, about 38% in 1950 as Can. M ed. Assoc. J. 76: 466-469, mol. 36: 247-249, 1953. opposed to 5 % to 6% in recent 1957. CORDES, F. C., AND W. D. HOMER. years. SMITH, H. E. Anterior chamber hem­ Contusion of the eyeball with de­ orrhages following nonperforating In our series, traumatic hyphema layed intraocular hemorrhage. Am. represented 4.3% of all cases ad­ ocular injuries. Rocky Mountain J. Ophthalmol. 15: 942-945, 1932. Med. J. 49: 844-848, 1952. mitted to the Eye Service. The age GLASER, B. Prophylaxis in traumatic span in these cases was from 2 to STOKES, J. H. Traumatic hyphema. hyphema. Am. J. Ophtha/mol. 50: Southern Med. J. 51: 1476-1479, 67 years, but 58% of the patients 747- 752, 1960a. 1958. were under age 15. The majority GLASER, B. Prophylaxis in traumatic THYGESON, P., and c. BEARD. Obser­ were males. No significant differ­ hyphema. Southern M ed. J. 57: vations on traumatic hyphema. ence in incidence was found be­ 195-200, 1964b. Am. J. Ophthalmol. 35: 977-985, tween the two eyes. Injuries oc­ GOLDBERG, J. L. Conjugated estro­ 1952. curred throughout the year, with gens in the prevention of secon­ WILKINSON, J. A. Traumatic hy­ some variation depending on the dary hyphema after ocular trauma. phema. J. Louisiana State Med. Soc. type of injury. Thrown rocks were A MA Arch. Ophthalmol. 63: 1001- 108: 56- 58, 1956. first among the causes of injury, 1004, 1960. WILSON, J. M., T. P. McKEE, E. M. followed by BB shots. GREGERSEN, E. Traumatic hyphaema. CAMPBELL, AND G. E. MILLER. Air Only 6.6% of the cases developed I. Report of 200 successive cases. injection in the treatment of trau­ secondary hemorrhage. This low Acta Opht'halmol. 40 : 192- 199, matic hyphema. Am. J. Ophthal­ incidence is attributable to prompt 1962. mol. 37: 409- 411, 1954. admission and treatment in the HENRY, M. M. Nonperforating eye hospital. However, once secondary injuries with hyphema. Am. J. Ophthalmol. 49 : 1298-1300, 1960. hemorrhage occurred, the prog­ nosis was poor; six out of the 10 Hi:iRVEN, I. Fibrinolysis and hyphema. The effect of "Thrombolysin" and cases resulted in blindness. Most "Kabikinas" on clotted blood in of the secondary hemorrhages oc­ camera anterior of the eye in rab­ curred on the third day following bits. Acta Ophtha/mol. 40: 320- injury. 326, 1962. Blood staining of the cornea oc­ KREMEN, A., AND M. R. HAGIGH. curred only in cases of secondary Management of traumatic hyphema. hemorrhage associated with glau­ Maryland State M ed. J. 8: 615- coma. 617, 1959.

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