Hyphema Diagnosis and Management

    • CE credits 2 hours
    • COPE code 55976-AS / 114818
    • Available until Dec 20, 2020



  • To review the pathophysiology and various causes of hyphema
  • To review management considerations for patients with hyphema
  • To review the positive and negative predictive value


A 23-year-old male presents to the emergency department after being assaulted 30 minutes previously. While under the influence of alcohol, he was in an altercation with another male on the street and suffered a blow to the left eye. He reports pain in around the left eye, as well as slightly decreased vision. There are no symptoms of diplopia, flashes, floaters, or visual field loss.

On exam, there is bruising of the left eyelid but no other apparent signs of trauma. Visual acuity is 20/20 and 20/50 corrected in the right and left eyes, respectively. Extraocular movements and confrontational visual fields are normal. Intraocular pressures are R 12 and L 16. Pupils are symmetric and both reactive to light, although the left appears more sluggish. There is no RAPD. Anterior segment exam is shown in the figure below of the left eye. The anterior chamber is deep with 2+ RBCs, 1+ WBC, 1+ pigment, 3+ flare, and wisps of fibrin near the pupillary margin. The lens and retina appear normal.

Quick Question

Which systemic condition would make this individual most prone to complications from his hyphema?

  • Haemophilia

    Although haemophilia should be considered in any patient with a spontaneous hyphema, it does not necessarily increase the risk of complications if managed appropriately.

  • Sickle cell disease

    Sickle cell disease is a major risk factor for complications secondary to hyphema, and in fact it is recommended that all non-Caucasian individuals should have a sickle screen as a routine investigation.

  • Sickle cell trait

    Patients with sickle cell trait should be managed similar to those with sickle cell disease, although they are at significantly less risk of complications related to erythrocyte sickling.

  • Idiopathic thrombocytopenia purpura (ITP)

    ITP is a condition characterized by a decrease in the number of platelets. Although a risk factor for hyphema, it does not increase the risk of complications to the degree that sickle cell disease does.


Hyphema is defined as blood within the anterior chamber and is caused by disruption of blood vessels within the iris or ciliary body.1 Most often, it occurs as a result of blunt or penetrating trauma to the eye, and is often found in association with other ocular injuries. It may also occur spontaneously, especially in the presence of a coagulopathy or vascular abnormality. In and of itself, it is generally a self-limiting condition causing no permanent vision loss. However, the related traumatic effects in the eye and orbit can be multiple.2

The mean annual incidence of hyphema is approximately 17 per 100,000 population per year,3 slightly more common in children and young adults. 4 It has a male predominance of 3 to 1.5 Mostly the term hyphema refers to the visible (i.e. macroscopic) form of hyphema, but it should be noted that a small degree of hemorrhage may occur which is not visible to the naked eye — this is termed a microhyphema.

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