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The treatment plan for traumatic hyphema should be directed at minimizing the possibility of

secondary hemorrhage, controlling inflammation, and mitigating elevated IOP. It is essential that
the patient wear a protective shield over the injured eye; restrict physical activity; elevate the
head of the bed; and be observed closely, with daily observation initially. To reduce the risk of
rebleeding, nonaspirin analgesics should be used for pain relief; however, even nonsteroidal anti-
inflammatory medications can increase the risk of rebleeding. Most patients can be managed on
an outpatient basis, but if satisfactory home care and outpatient observation cannot be ensured,
admission to the hospital may be required.
Most ophthalmologists administer long-acting topical cycloplegic agents initially to control
inflammation and improve patient comfort, facilitate posterior segment evaluation, and eliminate
iris movement. Topical corticosteroids are beneficial in controlling anterior chamber inflammation
and preventing synechiae formation, and they may play a role in preventing rebleeding. Oral
corticosteroids are controversial in the treatment of hyphema but may be used to facilitate the
resolution of severe inflammation and/or to prevent rebleeding.
Aggressive treatment of elevated IOP is important to reduce the risk of corneal blood staining
and optic atrophy. Topical antihypertensive agents (β-blockers and α-agonists) are the mainstay
of therapy, although intravenous or oral hyperosmotic agents may occasionally be required. If
medical management fails to control IOP, surgical evacuation of the blood may be required in
order to reduce the risk of permanent corneal blood staining.
Antifibrinolytic agents (eg, aminocaproic acid, tranexamic acid, prednisone) were previously
thought to reduce the incidence of rebleeding, but studies have shown no statistical improvement
in visual outcome. Because these agents can have significant adverse effects (eg, nausea,
vomiting, postural hypotension, muscle cramps, conjunctival suffusion, nasal stuffiness,
headache, rash, pruritus, dyspnea, toxic confusional states, and arrhythmias), they are rarely
used today in the treatment of hyphema.

Surgical intervention in traumatic hyphema


urgery should be performed at the earliest definitive detection of corneal blood staining. Some
authors suggest that surgery is indicated when IOP is higher than 25 mm Hg on average for 5
455days with a total hyphema or when IOP is higher than 60 mm Hg for 2 days. Patients with
preexisting optic nerve damage or sickle cell hemoglobinopathies may require earlier intervention.
Indications for surgical intervention are summarized in Table 1.

The simplest way to surgically treat a persistent anterior chamber clot is anterior chamber
irrigation with balanced salt solution through a limbal paracentesis. The goal is to remove
circulating red blood cells that may obstruct the trabecular meshwork; removal of the entire clot
is neither necessary nor wise because of the risk of a secondary hemorrhage. The irrigation
procedure can be repeated. If irrigation is not successful, the irrigation/aspiration handpiece, used
in cataract surgery, may be effective. The use of a cutting instrument or intraocular diathermy
may be necessary in severe cases. Iris damage, lens injury, endothelial cell trauma, and additional
bleeding are potentially serious complications of surgical intervention.

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