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Visual Outcomes of Hyphema in Closed Globe Injury, Managed at a Tertiary Care Institute

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Visual Outcomes of Hyphema in Closed Globe Injury, Managed at a Tertiary Care Institute Jebmh.com Original Research Article Visual Outcomes of Hyphema in Closed Globe Injury, Managed at a Tertiary Care Institute Prasanta Kumar Nanda1, Jayaram Meher2, Bishnuprasad Rath3 1Professor and HOD, Department of Ophthalmology, SCB Medical College and Hospital, Cuttack, Odisha. 2Postgraduate Resident, Department of Ophthalmology, SCB Medical College and Hospital, Cuttack, Odisha. 3Postgraduate Resident, Department of Ophthalmology, SCB Medical College and Hospital, Cuttack, Odisha. ABSTRACT BACKGROUND An accumulation of blood in the anterior chamber is known as hyphema. An injury Corresponding Author: to the eye or its surrounding tissue, constitutes most of the calls for emergency in Dr. Jayaram Meher, SR Hostel, Room No. 166, ophthalmology. This study aims to determine the causes and visual outcome SCB Medical College and Hospital, following treatment in patients with hyphema following closed globe injury. Cuttack, Odisha. E-mail: [email protected] METHODS DOI: 10.18410/jebmh/2020/15 This is a prospective study involving 76 patients which done from February 2019 to September 2019 in the Department Of Ophthalmology. Detailed history was Financial or Other Competing Interests: None. taken regarding the type, mode of injury, duration of injury and the eye affected. Lid and adnexal injuries, visual acuity at the time of admission were recorded. How to Cite This Article: Detailed anterior segment evaluation on slit lamp was done. Appropriate treatment Nanda PK, Meher J, Rath B. Visual was given. The patients were followed after 1 week, and at the end of 6 weeks. outcomes of hyphema in closed globe injury, managed at a tertiary care RESULTS institute. J. Evid. Based Med. Healthc. 2020; 7(2), 68-72. DOI: Majority of patients were males (62 cases, 81%). The most common age group 10.18410/jebmh/2020/15 affected was 15-30 years i.e. 65 patients (85%). Sports related injury (32 cases, 42%) was most common cause of hyphema followed by road traffic accident (20 Submission 09-12-2019, cases, 26%). Of the 76 patients, iris injuries were very common (35 cases). Other Peer Review 13-12-2019, ocular findings included- ecchymosis, subconjunctival haemorrhage and angle Acceptance 30-12-2019, Published 07-01-2020. recession. Moderate blood staining of cornea occurred in 3 patients. The most common form of hyphema in our study was grade-1 seen in 42 patients (55%). Anterior chamber wash done in 10 patients. Rest of the patients were observed carefully. The best corrected vision of 6/24 or better was noted in 68 patients (89%) at the last follow up. CONCLUSIONS Hyphema occurring as a result of blunt trauma, though alarming is also an easily manageable condition if necessary intervention is done early and adequately. Blunt trauma can be prevented by supervising during play or use of adequate protection at work. Early initial presentation for early diagnosis and treatment can help to prevent many ocular complications and better visual outcome after trauma. KEYWORDS Ocular Trauma, Hyphema, Visual Acuity J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 7/Issue 2/Jan. 13, 2020 Page 68 Jebmh.com Original Research Article BACKGROUND Associated Ocular Findings Angle recession, a separation between the longitudinal and 5 Eye injuries are a major and under-recognized cause of circular muscle fibres of the ciliary muscle, is the most disabling morbidity. The public health importance of ocular important associated anterior segment finding in traumatic trauma is undeniable. An injury to the eye or its surrounding hyphema. The amount of angle recession does not tissues, constitute most of the calls for emergency in necessarily correlate with the size of the hyphema or degree Ophthalmology. The trauma may range from simple of acute IOP elevation. The incidence of angle recession is 6,7,8 superficial injuries to devastating penetrating injuries of the variably reported as 30% to 85%. More extensive globe. The surgical management of such injuries is directed recession is associated with a higher incidence of late onset at the restoration of normal ocular anatomy and function. glaucoma, and it is estimated that approximately 6% to The ultimate goal being prevention of secondary 10% of hyphema patients will develop angle recession 9 complications and maximizing the patient’s visual prognosis. glaucoma. Traumatic iritis invariably accompanies Dramatic improvements in the surgical management of hyphema. Pigment liberation may result in endothelial ocular trauma have evolved over the past two decades. pigment dusting and increase the trabecular meshwork However, persistent inadequacy in the standardized pigmentation. Iris atrophy and a Vossius ring, signifying documentation of eye injury morbidity and treatment compression of the pupillary margin on the anterior lens outcome, limits the development and widespread capsule, may be seen. introduction of techniques for preventing and improving the prognosis of serious eye trauma. Guidelines for Surgical Intervention in Traumatic 10 Hyphema Traumatic Hyphema To prevent optic atrophy An accumulation of blood in the anterior chamber is known Operate before IOP averages > 50 mmHg for 5 days. as hyphema. Trauma producing bleeding into the anterior Operate before IOP averages > 35 mmHg for 7 days. chamber of the eye is common. Hyphaema can be primary, To prevent corneal blood staining secondary and recurrent. Operate before IOP averages >25 mmHg for 6 days Operate if there is any indication of early blood staining Primary Hyphema To prevent peripheral anterior synechiae It occurs at the time of the injury. The bleeding is self - Operate before a total hyphaema persists for 5 days. limiting, irrespective of whether it occurs from a small vessel Operate before a diffuse hyphaema involving most of the or a large vessel. This is because, equilibrium is maintained anterior chamber angle persists for 9 days. between the vascular and the intraocular pressure and once In hyphaema patients with sickle cell haemoglobinopathies a vessel of the iris ruptures, there is immediate contraction Operate if IOP averages ≥25 mmHg for 24 hours of its wall. If the haemorrhage is large, it suggests rupture Operate if IOP has repeated transient elevations > 30 of larger vessel near the root of the iris or, ciliary body mmHg. Secondary Hyphema Complications The haemorrhage occurs on the 2nd to 5th day, when there Higher risk of secondary glaucoma- Secondary glaucoma is clot lysis and retraction. Incidence of secondary can present acutely, or late in life even decades after an haemorrhage is variable: 5% to 30%.1 It is more common isolated injury. Outflow obstruction due to trabeculitis, when the amount of blood initially is large.2 clogging of trabecular meshwork by inflammatory cells & RBCs, break down products, mechanical occlusion of Recurrent Hyphema pupil by hyphema/clot. Rarely, haemorrhage into the anterior chamber recurs for Corneal blood staining- Total hyphema is associated with weeks or months. Recurrent hyphema following a blunt sudden visual loss, high IOP, extreme pain, nausea. If injury to the eye may at times be associated with a poorer hyphema persists longer, there is a risk of damage to the 11 prognosis than occurring from the initial trauma. The trabecular meshwork, uveitis & possible re-bleed. In presence of fresh blood in the anterior chamber, or an the study by Coles, the risk of elevated IOP was high for increase in the amount of blood in the anterior chamber is those whose hyphemas filling more than 50% of the 12 considered indicative of a recurrent bleeding. The risk anterior chamber, or a grade III hyphema. factors and the exact mechanism is not known. It is hypothesized, that, once the initial vasospasm is relieved or Management of such cases varies according to severity. after fibrinolysis occurs, the platelets can no longer adhere Uncomplicated/mild bleed are treated conservatively, with to the vessel wall or cannot aggregate. The initial clot which head elevation and rest. Patients with bleeding diathesis, re- is formed is expressed into the low – resistance anterior bleed, corneal staining, extreme IOP elevation will require chamber producing further haemorrhage.3 The reported energetic management. Medical management is done with incidence of secondary anterior chamber hemorrhage, that IOP lowering drugs such as topical aqueous suppressants, is, rebleeding, in the setting of traumatic hyphema ranges beta-blockers and alpha agonists. Systemic carbonic from 0% to 38%.4 anhydrase inhibitor like acetazolamide and hyperosmotic J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 7/Issue 2/Jan. 13, 2020 Page 69 Jebmh.com Original Research Article agent i.e. mannitol may be required if pressure doesn’t Any posterior segment pathology, neoplasia of ocular decrease with topical management. Cycloplegics, steroids tissues. may be required to control pain and Vascular anomaly or any bleeding diathesis. inflammation. Tranexamic acid may be given to prevent Patients on anti-coagulants and anti-platelets therapy. rebleed. Approximately 5 percent of patients with traumatic hyphema require surgery.13 Options in Surgical Management Anterior chamber irrigation and aspiration i.e. anterior chamber washout, hyphema evacuation using vitrectomy instrumentation Clot irrigation with a filtering procedure trabeculectomy when high IOP poses a risk. Anterior chamber paracentesis. Peripheral iridectomy, if pupillary block occurs due to total hyphema.14 METHODS This is a prospective
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