Hyphema Presented by Dr - PowerPoint Presentation

Slide1

Hyphema

Presented by

Dr

Aina

A.S.

Slide2

Outline

Defination

Causes

Classification/grading

Clinical features

Complication

Management

Prognosis

Conclusion

Slide3

Defination

Hyphema

is the presence of red blood cells in the anterior chamber of the eye.

A minimal amount of tiny red blood cells suspended in the aqueous

humour

is termed a

microhyphema

.it is visible only with Slit lamp.

A little blood in the aqueous can cause a significant decrease in VA.

Slide4

Slide5

Slide6

Causes

Traumatic

Spontaneous

neovascularization

(

eg

, diabetes mellitus, ischemia, cicatrix

formation,CRVO

)

vascular

anormalies

(

eg

, juvenile

xanthogranuloma

)

ocular

neoplasms

(

eg

, retinoblastoma, iris melanoma)

inflammatory processes(

uveitis

)

haematological

disorders (

eg

SCD,heamophilia,leakemia

)

Surgery (intra

op,early

post op & late post op)

laser

trabeculoplasty

or

iridotomy

Anticoagulation therapy such as

warfarin,aspirin

idiopathic

Slide7

Traumatic

Blunt or penetrating.

Ranges from serious injury to trivial ones

Affects both children and adult. Males>> females.

These includes impact from missiles, balls, rocks, projectile toys, air gun pellets, hockey pucks, wood, RTA, and the human fist.

Accidental or intentional(Surgery)

Slide8

Grading of

Hyphema

Grade 1 - Layered blood occupying less than one third of the AC

Grade 2 - Blood filling one third to one half of the AC

Grade 3 - Layered blood filling one half to less than total of the AC

Grade 4 - Total clotted blood, often referred to as blackball or 8-ball

hyphema

or button hole.

Slide9

It can also be done by measuring (in millimeters) the

hyphema

from the inferior 6-o'clock

limbus

.

Digital imaging analysis is also useful and objective but is available in only a few research or academic facilities.

Also in percentage.

Slide10

Clinical features

Depend on the severity of the injury.

It includes diminished visual

acuity,pain

, photophobia,

lacrimation

, headache, vomiting, nausea and somnolence/lethargy.

Elevated Intraocular Pressure

more commonly associated with near total or total

hyphemas

however it can occur in

hyphema

of any magnitude.

Usually occurs in the acute phase ≈ 24hrs this is then followed by a period of normal or below normal pressure from the 2

nd

-6

th

day.

Slide11

The early period of elevated IOP is probably the result of

trabecular

plugging by erythrocytes and fibrin.

This follows period of reduced pressure most likely due to reduced aqueous production and

uveitis

, and it may actually increase the chance of secondary hemorrhage. This period of

hypotony

is commonly followed by a subsequent rise in IOP, probably coincidental with the recovery of the

ciliary

body.

It now later subsides with recovery of the

trabecular

meshwork and disappearance of the

hyphema

.

Careful monitoring of the IOP is important and may determine the course of treatment.

Slide12

Exceptions in 75% to total

hyphema

in whom pressure elevation frequently has its onset simultaneously with the initial

hyphema

and remains continually elevated until the

hyphema

has had considerable resolution.

When large segments of the AC angle are irreparably damaged.

When organization of the fibrin or clot produces extensive peripheral anterior

synechiae

, the IOP rises, becoming intractable glaucoma.

Slide13

Causes of raised IOP

RBC blocking aqueous drainage

Inflammatory cells blocking aqueous drainage

Posterior

Synechiae

Peripheral Anterior

Synechiae

8 ball

hyphema

Slide14

Complications

Secondary Hemorrhage

Posterior

synechiae

.

Peripheral anterior

synechiae

.

Corneal

bloodstaining

.

Optic atrophy

Secondary glaucoma

Slide15

Secondary Hemorrhage

It worsens the prognosis and occurs in 25% of all patients with

hyphema

.

Probably due to

lysis

and retraction of the clot and fibrin aggregates that have occluded the initially traumatized vessel.

It is commoner in the young and occurs about 3

rd

-4

th

day though can still occur 7

th

day

posttrauma

.

Grade 3 to Grade 4

hyphema

Heamophilia

is known to be

asso.with

high incidence of

rebleeding

.

Slide16

Posterior synechiae.

Usually in patients with traumatic

hyphema

. This complication is 2

0

to

iritis

or

iridocyclitis

. However, they are relatively rare complications in patients who are medically treated.

Posterior

synechiae

occur more frequently in patients who have had surgical evacuation of the

hyphema

.

Slide17

Peripheral anterior synechiae.

Occur frequently in medically treated patients in whom the

hyphema

has remained in the AC for a prolonged period, typically 9 or more days.

The pathogenesis may be due to a prolonged

iritis

asso

. with the initial trauma and/or chemical

iritis

resulting from blood in the AC also the clot in the chamber angle may subsequently organize, producing

trabecular

meshwork fibrosis that closes the angle.

Slide18

Corneal bloodstaining

It primarily occurs in patients with a total

hyphema

and

asso

. elevation of IOP.

factors that affect endothelial integrity may enhance it occurrence-

Initial state of the corneal endothelium; decreased viability resulting from trauma or advanced age (

eg

, cornea

guttata

)

Surgical trauma to the endothelium

Large amount of formed clot in contact with the endothelium.(Total

hyphema

≈ 6 days)

Prolonged elevation of IOP > 25mmHg.

It starts centrally and spread peripherally.

Slide19

Optic atrophy

It can result from either acute, transiently elevated IOP or chronically elevated IOP.

Pallor occurs with constant pressure of 50 mm Hg or higher for 5 days

or

35 mm Hg or higher for 7 days.

SCD patient can develop disc pallor with pressure of 35mmHg in 2-4 days.

Slide20

Secondary glaucoma

Prolong elevated IOP may lead to glaucoma.

As gradual clearing of the

hyphema

occurs, with erythrocytes losing hemoglobin and becoming ghost cells in the vitreous cavity.

The ghost cells then circulate forward into the AC, with resultant

trabecular

blockage due to the distorted, bulky configuration of the

crenated

red blood cell.

So this delayed elevation of IOP may cause

ghost cell glaucoma

, particularly in patients with poor facility of outflow.

Slide21

When large segments of the AC angle are irreparably damaged and/or when organization of the fibrin or clot produces extensive peripheral anterior

synechiae

, the elevated IOP continues, becoming intractable glaucoma.

Slide22

Other complications of Hyphema

Choroidal

rupture.

Macular scarring.

Retinal detachment.

Vitreous hemorrhage.

Zonular

dialysis.

Lens opacities

Angle-recession glaucoma.

Secondary macular edema

Sympathetic

Ophthalmitis

.

Slide23

Management

Take a good history-trauma, PMH, POH

Complain of monocular worsening of visual acuity from normal vision to light perception.

Proper examination-

Assess the level/grade

Asso

. Ocular injuries.

Ocular motility.

Pupillary

function.

Gonioscopy

.

Visual field assessment

Slide24

Work-up

Full blood count

Hemoglobin electrophoresis

Ocular USS

prothrombin

time (PT) and partial

thromboplastin

time (PTT).

X-ray of the orbit

Infrequently, a B-scan and/or a CT scan may be necessary to rule out an intraocular tumor or a foreign body.

Rarely, an iris

fluorescein

angiogram may be needed if early iris

neovascularization

is suspected as an underlying cause of the

hyphema

.

Slide25

Medical Management

The usual treatment of patients with

hyphema

include hospitalization, bed rest, bilateral patching, topical

cycloplegics

, topical steroids, systemic steroids, topical

antiglaucomatous

medications, systemic CAI and sedation.

Avoid any

antiplatelet

drug such as aspirin and NSAIDS.

Slide26

Hospitalization

If the

hyphema

occupies more than one third of the AC.

IOP elevated beyond 30 mm Hg.

If patient has Sickle cell trait or

anaemia

or

rebleed

.

severe loss or decrease in vision.

Non-compliant patients.

While on bed; nurse in Fowler's position(30

0

-45

0

).

Daily measuring of IOP, 2X IOP if elevated .

Daily Slit lamp exam so as identify early stages of cornea staining.

Slide27

Surgical Intervention

Surgical intervention is usually indicated on or after the 4

th

day. Indications includes-

Microscopic corneal blood staining (at any time)

Total

hyphema

with intraocular pressures of 50 mm Hg or more for 4 days (to prevent optic atrophy)

Total

hyphemas

or

hyphemas

filling >75% of the AC present for 6 days with pressures of 25 mm Hg or more (to prevent corneal

bloodstaining

)

Hyphemas

> 50% of the AC retained longer than 8-9 days (to prevent peripheral anterior

synechiae

)

In patients with sickle cell trait or sickle cell disease who have

hyphemas

of any size that are associated with IOP of >35 mm Hg for more than 24 hours.

Slide28

Techniques to surgery

Hyphema

evacuation with closed

vitrectomy

instrumentation.

Paracentesis

Irrigation and aspiration through a small incision

Clot irrigation with

trabeculectomy

Hyphema

surgery should be preceded by intravenous

acetazolamide

and

mannitol

if the IOP is elevated.

It should be performed under GA in all patients.

Slide29

Complications of surgery

include damage to the

corneal endothelium,

the lens

the iris

prolapse

of the intraocular contents

rebleeding

and

increased

synechiae

formation.

Slide30

Hyphema in SCD

The

sickled

erythrocytes obstruct the

trabecular

meshwork more effectively than healthy cells, and a consequent elevation of intraocular pressure occurs with lesser amounts of

hyphema

.

Use of CAI is highly cautioned in SCD because it causes metabolic acidosis and this will provoke crisis in them.

Slide31

Uveitis

-glaucoma-

hyphema

(UGH) syndrome is seen weeks to months after surgery.

It is associated with archaic design AC IOLs and

sulcus

PC IOLs, the treatment may require removal of the lens that is causing the problem and replacing it with another lens.

Slide32

Prognosis

The success of

hyphema

treatment is judged by the recovery of VA, is good in ≈ 75% of patients.

It is directly related to the following-

Grade of

hyphema

Amount of associated damage to other ocular structures (

ie

,

choroidal

rupture, macular scarring, Retinal detachment)

Whether secondary hemorrhage occurs

Whether complications of glaucoma, corneal blood staining, or optic atrophy occur.

Slide33

Conclusion

Hyphema

is one of the ocular conditions that can eventually lead to total blindness good and adequate knowledge of its management will definitely go a long way in reducing incidence of visual loss in our community.

The eye is an organ that represents only 0.3% of the total surface area of the human body. However, loss of vision in one or both eyes has been classified as 24% or 85% whole person impairment or disability, respectively.

Slide34

Finally

i

enjoy all my fellow eye care providers to be thorough and hardworking in discharging their duties whole heartedly so that we can together minimize the global burden of visual impairment and hence achieve

VISION 2020 ‘RIGHT TO SIGHT’.

Slide35

THANK YOU FOR LISTENING