PHOTO ESSAY: Idiopathic Atypical Hyphema

PHOTO ESSAY: Idiopathic Atypical Hyphema
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ABSTRACT

Hyphema is the accumulation of red blood cells in the anterior chamber of the eye. Blood accumulates from the disruption of vessels of the iris or ciliary body. Trauma is the most common risk factor, however, spontaneous hyphema can also result from other causes, including an underlying medical condition.1

Keywords: hyphema, spontaneous hyphema, anterior chamber

 

CASE REPORT

A 66-year-old white female presented to the clinic for urgent evaluation secondary to sudden onset blurry vision and halo around lights upon awakening. She looked in the mirror and noticed a “brown line” in the center of her left eye. She denied trauma but reported having COVID a few weeks prior and was having a post-viral cough. She reported waking up that morning coughing profusely. She denied heavy lifting, blunt trauma to the eye or any head injury. She was asymptomatic for pain, discharge, discomfort, or photophobia. She had a history of hypertension, well controlled on lisinopril; she had checked her blood pressure that morning and reported that it was normal. She denied a history of diabetes or sickle cell disease. She only wore reading glasses and her last eye exam was over 30 years prior.

Her uncorrected acuity was 20/25-2 OD and 20/20 OS. Her eye pressures were 17mmHg OD and 21mmHg OS. Pupillary function, visual field testing and ocular motilities were normal. Slit lamp exam revealed 4+ pigmented/red blood cells, and a clotted strain of blood from the temporal iris margin was visible OS. She had 1+ nuclear cataracts OU. Dilated fundus exam was unremarkable OU. Gonioscopy OS was open to scleral spur in all quadrants with a microhyphema, but no neovascularization, mass or other abnormalities were noted.

She was prescribed Pred Forte 1% four times a day OS and cyclopentolate 1% once a day until the next visit, was advised to sleep with her head elevated and to refrain from strenuous activities until resolution of the hyphema.

The patient returned three days later for follow up, reporting using drops as prescribed without issues, reported that her vision had improved and she no longer saw halos around lights. Upon slit lamp exam, the hyphema was resolved. No anterior chamber or vitreous cells were noted. She was advised to discontinue cyclopentolate drops and start tapering Pred Forte by decreasing a drop every two days then discontinue. She returned for one more follow up four weeks later and the eye was quiet. There have been no recurrences since the initial presentation

 

DISCUSSION

The most common cause of hyphema is blunt eye trauma, but it can also happen after intraocular surgery, spontaneously in conjunction with ocular inflammation (i.e. herpes zoster, anterior uveitis, iris melanoma, rubeosis iridis, etc), in association with certain medications (i.e. aspirin or warfarin), or in association with systemic diseases (leukemia, sickle cell disease, bleeding dyscrasias, clotting disorders).2

Patients may present with a decrease in vision, photophobia, eye pain and/or increase in eye pressure.3 It often occurs in patients with medical conditions that predispose them to ischemia. It is important to obtain a thorough history and ask about bleeding disorders, anticoagulation therapy, clotting disorders or sickle cell disease. Physical examination should include visual acuity, pupillary response, extra ocular movements, visual field by confrontation, intraocular pressure, slit-lamp examination, fundus examination and gonioscopy to evaluate the trabecular meshwork and rule out any abnormalities of the iridocorneal angle. An open globe should be excluded prior to any procedure that might apply pressure on the eye.2

Management depends on severity; it is important to monitor intraocular pressure closely as blood cells can clog the trabecular meshwork. Patients should maintain a head elevation position to facilitate the blood to settle down, to avoid visual obstruction and to prevent corneal endothelial cell exposure to red blood cells. Topical or systemic corticosteroids may be used to reduce inflammation and cycloplegic agents can be used to stop ciliary spasm and improve photophobia. Beta-blockers or alpha-agonists can be used to decrease intraocular pressure if elevated. Surgical intervention might be needed in the case of severe trauma or if eye pressure cannot be controlled with topical or oral agents. In certain situations, such as severe orbital injury or in a patient with blood dyscrasia, hospitalization for close monitoring might be recommended.3

The prognosis varies depending on cause and severity of hyphema. For spontaneous mild cases as the one described here, prognosis is excellent and the risk of complications is low. In the case of hyphema associated with a systemic condition, including sickle cell or clotting disorders, there is an increased risk for vision loss because of greater frequency of rebleeding.

Given that the patient’s hyphema resolved in a short period of time without recurrence, her medical history was only significant only for well controlled hypertension, and that she was following closely with her primary care provider a workup was not deemed necessary. The working diagnosis is that her spontaneous hyphema was likely caused by her profuse post-viral cough. She was advised to monitor for any change to her vision or ocular appearance,  and to return immediately for an evaluation should any changes be noted. A more thorough work up would be indicated with any recurrence.

 

REFERENCES

  1. Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70.
  2. Miller KN, Collins CL, Chounthirath T, Smith GA. Pediatric Sports- and Recreation-Related Eye Injuries Treated in US Emergency Departments. Pediatrics. 2018 Feb;141(2)
  3. Gharaibeh A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2013 Dec 03;12(12):CD005431.
UMass Memorial | Worcester, MA

Dr. Ana Bonaldi earned her optometry degree from MCPHS, where she graduated salutatorian, and completed an ocular disease residency at the Boston Department of Veteran Affairs. She then joined UMass Memorial as an instructor in the department of Ophthalmology and Visual Sciences, where she is in clinic and also teaches ophthalmology residents.

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