Injuries to the face are commonly encountered when caring for children. We have previously reviewed several facial injury topics (see, Mandibular Fractures, Dental Trauma, Tongue Lacerations, and Eyelid Lacerations). Eye injuries can sometimes be under appreciated, especially when there are other associated injuries. One simple finding that we should pay particular attention to is the presence of a Hyphema.
Traumatic Hyphema: Basics
Ocular trauma is a leading cause of non-congenital, monocular blindness in children worldwide. [Yildiz, 2016; SooHoo, 2013]
Hyphema = blood in the anterior chamber of the eye. [Trief, 2013]
Deformity of the globe leads to displacement of the lens and iris, possibly tearing the ciliary body and/or iris vessels.
Bleeding will increase the intraocular pressure, which assists tamponading the bleeding along with clot formation.
Clot integrity is best 4-7 days after the injury.
Traumatic hyphema is more common in children than in adults. [SooHoo, 2013; Tries, 2013]
Most commonly occurs from blunt injury (~75%). [Trief, 2013]
Projectiles (like airsoft/BB guns, paintball guns) [Shazly, 2012]
Sports
Airbags deployed during MVC [Motlery, 2003]
Assault, Non-accidental Trauma [Calzada, 2003]
Miscellaneous items (hanger, towel, rubber toy snake) [SooHoo, 2013]
Traumatic Hyphema: Complications
Rebleed / second hemorrhage
Associated with a worse prognosis.
Typically occurs within first 4 days after injury.
Corneal staining (~5% of cases)
Can lead to amblyopia.
May require surgery to resolve.
Increased intraocular pressure
Synechiae
Glaucoma
Amblyopia
Visual Impairment [Yildiz, 2016]
Traumatic Hyphema: Evaluation
Don’t get distracted!
Evaluate for other associated traumatic injuries.
Evaluate for Open Globe Injuries!
The presence of a hyphema should heighten the concern for open globe injury.
History of lacerating injuries, small projectiles, or sharp objects also warrants greater concern for open globe injuries.
Look specifically for anisocoria and afferent pupillary defect.
A portable slit-lamp is a very useful tool!! Ultrasound, used carefully, can also help evaluate globe integrity.
Check intraocular pressure
Only do this if confident that there is not open globe injury.
This can be challenging in children, but is very important.
Characterizing the hyphema can help communicate to consultants and helps to determine potential risk for complications. [Trief, 2013]
Having patient sit upright will allow hyphema to settle.
Hyphemas can be characterized as Microscopic or Macroscopic.
Macroscopic hyphemas are graded by the height of the blood in the anterior chamber (AC).
Grade 1: Less than 1/3 of the AC; Best prognosis
Grade 2: 1/3 to 1/2 of the AC
Grade 3: 1/2 to nearly the entire AC
Grade 4: Fills the entire AC; Worse prognosis
Finish the complete eye exam.
Fundoscopic exam should be used to look for vitreous hemorrhage. [Trief, 2013]
Ultrasound can help characterize the posterior chamber, especially if there is a Grade 3 or 4 hyphema.
Visual acuity should also be documented.
History of Sickle Cell Disease, Sickle Cell Trait or other Bleeding Disorders (Hemophilia, Von Willebrands) should be considered.
Patients with sickle cell disease and trait are at risk for developing hyphema, even spontaneously.
It is important to inquire about possible sickle cell disease/trait in the family. [Trief, 2013]
Patients have been diagnosed with sickle cell disease/trait following traumatic hyphema. [SooHoo, 2013]
Traumatic Hyphema: Treatment
Outpatient care is most often successful. [SooHoo, 2013]
Basic care consists of:
Head of Bed 30-45 degrees.
Relative rest / limited activity
Avoiding Aspirin or NSAIDS.
Refraining from reading (or watching electronic devices up close) as accommodation can stress the injured vessels. [Trief, 2013]
Protective eye shield recommended by some.
Close Ophthalmology follow-up (sometimes daily).
Medication strategies include: [Trief, 2013]
Suppress aqueous production
Topical Beta Blockers
Carbonic anhydrase inhibitors (avoid if Sickle Cell Disease present)
Cycloplegics
Helps with comfort.
May reduced secondary hemorrhage risk.
Topical atropine, cyclopentolate, or scopolamine.
Steroids
Topical or systemic have been used.
Help to reduced inflammation and stabilize clot.
Avoid long-term use as it will increase risk of cataracts and glaucoma.
Antifibrinolytics
Decreases rates of secondary bleeding.
Aminocaproic acid is commonly used.
TXA has been found to be safe, although has less literature to show its benefits. [Albiani, 2008]
Inpatient care should be considered for patients with:
Sickle cell anemia/trait
Grade 3 or Grade 4 Hyphema
Penetrating ocular trauma
Secondary bleed
History concerning for abuse
Poor ability to adhere to the medical plan.
Surgery may be required in those who have:
Corneal staining
Uncontrolled increased intraocular pressures
Grade 4 hyphema that persists for >5 days
Large clots persisting > 10days
References
Yildiz M1, Kıvanç SA1, Akova-Budak B1, Ozmen AT1, Çevik SG2. An Important Cause of Blindness in Children: Open Globe Injuries. J Ophthalmol. 2016;2016:7173515. PMID: 27247799. [PubMed] [Read by QxMD]
Objective. Our aim was to present and evaluate the predictive factors of visual impairment and blindness according to WHO criteria in pediatric open globe injuries. Methods. The medical records of 94 patients younger than 18 years who underwent primary repair surgery were reviewed retrospectively. The initial and final visual acuity, anterior and posterior segment findings, and zone of injury were noted. The patients were classified as blindness […]
Trief D, Adebona OT, Turalba AV, Shah AS. The pediatric traumatic hyphema. Int Ophthalmol Clin. 2013 Fall;53(4):43-57. PMID: 24088932. [PubMed] [Read by QxMD]
SooHoo JR1, Davies BW, Braverman RS, Enzenauer RW, McCourt EA. Pediatric traumatic hyphema: a review of 138 consecutive cases. J AAPOS. 2013 Dec;17(6):565-7. PMID: 24215806. [PubMed] [Read by QxMD]
To report the demographics and outcomes in children (<18 years of age) who developed hyphema from ocular trauma and were subsequently cared for at a tertiary medical center. […]
Shazly TA1, Al-Hussaini AK. Pediatric ocular injuries from airsoft toy guns. J Pediatr Ophthalmol Strabismus. 2012 Jan-Feb;49(1):54-7. PMID: 21261240. [PubMed] [Read by QxMD]
To report ocular injuries caused by airsoft guns in children. […]
Liu ML1, Chang YS, Tseng SH, Cheng HC, Huang FC, Shih MH, Hsu SM, Kuo PH. Major pediatric ocular trauma in Taiwan. J Pediatr Ophthalmol Strabismus. 2010 Mar-Apr;47(2):88-95. PMID: 20349901. [PubMed] [Read by QxMD]
To investigate major pediatric ocular trauma in Taiwan. […]
Albiani DA1, Hodge WG, Pan YI, Urton TE, Clarke WN. Tranexamic acid in the treatment of pediatric traumatic hyphema. Can J Ophthalmol. 2008 Aug;43(4):428-31. PMID: 18711456. [PubMed] [Read by QxMD]
This study was undertaken to determine whether a difference exists in treatment outcome between patients treated with tranexamic acid (TEA) plus topical steroids and those treated with topical steroids alone. […]
Salvin JH1. Systematic approach to pediatric ocular trauma. Curr Opin Ophthalmol. 2007 Sep;18(5):366-72. PMID: 17700228. [PubMed] [Read by QxMD]
The aim of this article is to evaluate and review the scientific literature on pediatric ocular trauma from the past several years. Recent advancements have recognized mechanisms of injury that may be unique to children, require different treatment course than adults, and raise multiple public health concerns. […]
Motley WW 3rd1, Kaufman AH, West CE. Pediatric airbag-associated ocular trauma and endothelial cell loss. J AAPOS. 2003 Dec;7(6):380-3. PMID: 14730288. [PubMed] [Read by QxMD]
Airbag-associated ocular trauma among the adult population has been widely reported, but reports of these injuries in children are sparse. Laboratory experiments suggest that airbag-associated ocular trauma may cause endothelial cell loss, but reports of in vivo human endothelial cell counts are anecdotal. […]
Calzada JI1, Kerr NC. Traumatic hyphemas in children secondary to corporal punishment with a belt. Am J Ophthalmol. 2003 May;135(5):719-20. PMID: 12719088. [PubMed] [Read by QxMD]
To report the severity of ocular injury in seven children with traumatic hyphemas resulting from the accidental striking of the child in the face with a belt during the administration of corporal punishment. […]
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