What Is a Hyphema (Bleeding in Eye)?
Trauma to the eye can cause bleeding into the front of the eye, in the space between the cornea and the iris (anterior chamber). The blood that collects in the anterior chamber is called a hyphema.
What Causes Hyphema?
- Traumatic hyphema is the most common cause of hyphema. The trauma need not be penetrating or perforating; traumatic hyphema is often seen with blunt trauma, too.
- Bleeding from abnormal iris blood vessels as seen in advanced diabetes (rubeosis iridis neovascularization) or ischemic diseases of the eye
- Clotting disorders, blood dyscrasias (abnormalities of the blood cells or clotting), or anticoagulation medications (for example, warfarin)
- Postsurgical bleeding following intraocular surgery for cataract (particularly in cases in which the lens implant may be rubbing against the iris) or glaucoma
- Blood in the anterior chamber can also come from a source behind the anterior chamber, as seen in certain vitreoretinal diseases (vitreous hemorrhage, retinal vascular diseases, and others)
- Spontaneous nontraumatic hyphema in children can be associated with juvenile xanthogranuloma, retinoblastoma, and leukemia.
- "UGH" syndrome, or uveitis-glaucoma-hyphema syndrome, is an uncommon condition associated with recurring spontaneous hyphema.
- Less commonly, bleeding can come from a very inflamed iris (for example, herpes eye disease).
Trauma to the eye may initially cause a small hyphema. More severe bleeding may follow in three to five days. This trauma is usually blunt or closed trauma, and it may be the result of an athletic injury from a flying object, a stick, a ball, or another player's elbow. Other causes include industrial accidents, falls, and fights.
What Are the Symptoms of a Hyphema?
- Pain in or around the eye, especially if there is an associated rise in eye pressure
- Light sensitivity and a cramp-like ache called ciliary body spasm are often present with ocular trauma.
- Blurred vision, since the light entering the eye is partially or completely blocked by the presence of blood
What Are Hyphema Signs?
- When the amount of blood is small, the blood cells are visible under the slit lamp (the microscope used by eye doctors to examine the eyes). This is referred to as a microhyphema.
- Medium-sized hyphemas are sometimes visible to the naked eye as a layer of blood that is seen pooling in the anterior chamber with gravity.
- Large amounts of blood can fill the entire anterior chamber, obscuring the view of the iris and the pupil. These are called complete, or "eight ball" hyphemas.
- The white part of the eye may be red (conjunctival swelling) as well, which could be a sign of elevated intraocular pressure and/or inflammation (for example, traumatic iritis).
When Should Someone Seek Medical Care for a Hyphema?
Hyphema is a medical emergency. Call your ophthalmologist (a medical doctor who specializes in eye care and surgery) for an immediate appointment. If you cannot contact your ophthalmologist, go to a hospital's emergency department.
It will be important to identify and treat the underlying cause of the hyphema since many underlying causes pose a threat to vision. This is true of both traumatic and nontraumatic hyphema.
Also, close monitoring of the eye pressure is crucial. Elevated intraocular pressure puts the eye at further risk of permanent, irreversible vision loss. This is because very high eye pressure, or even moderately elevated eye pressure for prolonged periods, can result in glaucomatous optic atrophy (damage to the optic nerve).
A long-standing hyphema can also stain the cornea, causing further vision loss.
Questions to Ask the Doctor About Hyphemas
- What is the size of the hyphema?
- Are there any signs of damage to the eye? Could there be damage that develops over the long term?
- Does the cause of the hyphema pose a threat to the eye's health in the future?
- Is the eye pressure high, and if not, when should it be rechecked?
- Does the hyphema need to be surgically removed (evacuated) to reduce the chances of corneal staining or to control eye pressure?
- How can I prevent this from happening again?
- When may I resume my regular activities?
Bleeding in Eye (Subconjunctival Hemorrhage)
Subconjunctival Hemorrhage Symptoms
Most of the time, no symptoms are associated with a subconjunctival hemorrhage other than seeing blood over the white part of the eye.
- Very rarely do people experience any pain when the hemorrhage begins. When the bleeding first occurs, you may experience a sense of fullness in the eye or under the lid.
- The hemorrhage itself is an obvious, sharply outlined bright red area overlying the sclera. The entire white part of the eye may occasionally be covered by blood.
- In a spontaneous subconjunctival hemorrhage, no blood will exit from the eye. If you blot the eye with a tissue, there should be no blood on the tissue.
- The hemorrhage will appear larger within the first 24 hours after its onset and then will slowly decrease in size as the blood is absorbed.
What Exams and Tests Diagnose Hyphema?
Your ophthalmologist will take a detailed medical history. Your ocular history is important (injuries, prior eye surgeries, eye diseases), as is your general medical history. For example, do you take blood thinners or have a history of blood clotting disorders? Do you have sickle cell disease, sickle cell trait, or thalassemia? Some of these underlying medical conditions affect the healing time and the prognosis of traumatic hyphemas.
A complete eye examination is performed:
- Visual acuity is measured to assess blurred vision. This test checks for how well you can see.
- The intraocular pressure (pressure inside the eye) is measured.
- The eye is carefully examined with a slit lamp microscope. The pupil may be dilated to get a better view of the back part of the eye.
- Special imaging studies may be performed. An ultrasound of the eye may be helpful if the blood is blocking the view to the back of the eye. In traumatic hyphema, a CT scan may be necessary to assess the extent of the damage.
- Blood tests may be ordered to look for clotting disorders or diseases that affect the ability to form clots, such as hemophilia. African Americans and those of Mediterranean descent should be screened for sickle cell trait or disease and thalassemia. The risk of hyphema complications is much higher in people with sickle cell disease and thalassemia. The red blood cells change shape (sickle) and cannot clear from the anterior chamber as easily. This leads to higher and prolonged rises in eye pressure, which can result in vision loss due to glaucomatous optic atrophy and/or corneal blood staining.
Are There Home Remedies for Hyphema?
Hospitalization may be recommended in case close observation is necessary.
Most of the time, however, you will stay home but will need repeat visits to the eye doctor for follow-up. As the blood clears (reabsorbs) with time, the main concerns are whether the eye pressure rises, whether the cornea is in danger of staining, and whether there is rebleeding (secondary hemorrhage) as the clot contracts. It's for these reasons that you will need close follow-up.
Your eye doctor might recommend rest and keeping the head of your bed slightly elevated to ease the settling of the blood.
Avoid vigorous physical activity and any direct pressure on the eye (for example, eye rubbing), which can cause the clot to dislodge prematurely and result in more bleeding.
A shield might be placed over the eye to guard against rubbing the eyes.
Be sure to follow your doctor's instructions for taking drops and/or oral medications prescribed to manage intraocular pressure, prevent secondary hemorrhage (rebleeding), and control inflammation.
If you notice increased pain or decreased vision, notify your eye doctor immediately.
What Is the Treatment for a Hyphema?
- To control elevated eye pressure, pressure-lowering medications (eyedrops and/or pills) will be prescribed.
- Dilating drops (cycloplegics such as cyclopentolate) are often given to relieve some of the cramping sensation that people often feel and to minimize movement of the iris to decrease the chance of a secondary hemorrhage (rebleeding).
- In some cases, an anti-inflammatory (steroid) eyedrop or pill is prescribed, as well.
- Secondary hemorrhage (rebleeding) may occur if the clot dissolves before the broken blood vessels have had a chance to heal. For this reason, medications like aminocaproic acid or tranexamic acid are sometimes prescribed. Aminocaproic acid and tranexamic acid are antifibronolytics, which are medications that help stabilize the clot while the vessels heal, thus reducing the chance of a rebleed.
- You may be asked to limit medications that are known to increase bleeding risk such aspirin, ibuprofen, or blood thinners if it is safe to do so.
- Anti-nausea medication may be given to prevent you from vomiting.
What Is the Follow-up for Hyphema?
The number and frequency of follow-up visits will vary from person to person, depending on how quickly the blood is clearing and whether there is high eye pressure or corneal staining.
Surgical treatment to remove the hyphema may become necessary in the following circumstances:
- The eye pressure is too high, or elevated for too long in spite of treatment with pressure-lowering medications. (Elevated eye pressure could lead to permanent vision loss due to glaucomatous optic nerve atrophy.)
- The cornea is in danger of becoming stained. This could lead to clouding of the cornea that can blur the vision. A corneal transplant might be necessary in the future if the cornea is permanently damaged.
- The hyphema is not clearing in time. If a large hyphema still remains at the end of the first week, there is an increased risk that internal scarring in the eye called peripheral anterior synechiae (PAS) could form. Synechiae block the normal flow of fluid within the eye, resulting in high eye pressure. This can ultimately lead to glaucoma and vision loss.
How Do You Prevent Hyphemas?
It is wise to wear protective eyewear when you play a sport or work on hobbies and jobs in which there is a chance of traumatic hyphema from the eye being hit. Also keep in mind that around the holidays, fireworks, and flying champagne corks commonly cause eye injuries.
Reviewed on 2/26/2018
Albiani, D.A., et al. "Tranexamic acid in the treatment of pediatric traumatic hyphema." Can J Ophthalmol. 43.4 Aug. 2008: 428-431.
Bansal, S., et al. "Controversies in the pathophysiology and management of hyphema." Surv Ophthalmol. 61.3 May-June 2016: 297-308.