Secondary hemorrhage in traumatic hyphema

Medical interventions for traumatic hyphema

BACKGROUND

Traumatic hyphema is the entry of blood into the anterior chamber, the space between the cornea and iris, following significant injury to the eye. Hyphema may be associated with significant complications that uncommonly cause permanent vision loss. Complications include elevated intraocular pressure, corneal blood staining, anterior and posterior synechiae, and optic nerve atrophy. People with sickle cell trait or disease may be particularly susceptible to increases in intraocular pressure and optic atrophy. Rebleeding is associated with an increase in the rate and severity of complications.

OBJECTIVES

To assess the effectiveness of various medical interventions in the management of traumatic hyphema.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 3); MEDLINE Ovid; Embase.com; PubMed (1948 to March 2022); the ISRCTN registry; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The last date of the search was 22 March 2022.

SELECTION CRITERIA

Two review authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. We included randomized and quasi-randomized trials that compared various medical (non-surgical) interventions versus other medical interventions or control groups for the treatment of traumatic hyphema following closed-globe trauma. We applied no restrictions on age, gender, severity of the closed-globe trauma, or level of visual acuity at time of enrollment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 23 randomized and seven quasi-randomized studies with a total of 2969 participants. Interventions included antifibrinolytic agents (systemic and topical aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest. We found no evidence of an effect on visual acuity for any intervention, whether measured within two weeks (short term) or for longer periods. In a meta-analysis of two trials, we found no evidence of an effect of aminocaproic acid on long-term visual acuity (RR 1.03, 95% confidence interval (CI) 0.82 to 1.29) or final visual acuity measured up to three years after the hyphema (RR 1.05, 95% CI 0.93 to 1.18). Oral tranexamic acid appeared to provide little to no benefit on visual acuity in four trials (RR 1.12, 95% CI 1.00 to 1.25). The remaining trials evaluated the effects of various interventions on short-term visual acuity; none of these interventions was measured in more than one trial. No intervention showed a statistically significant effect (RRs ranged from 0.75 to 1.10). Similarly, visual acuity measured for longer periods in four trials evaluating different interventions was also not statistically significant (RRs ranged from 0.82 to 1.02). The evidence supporting these findings was of low or very low certainty. Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (RR 0.28, 95% CI 0.13 to 0.60), as assessed in six trials with 330 participants. A sensitivity analysis omitting two studies not using an intention-to-treat analysis reduced the strength of the evidence (RR 0.43, 95% CI 0.17 to 1.08). We obtained similar results for topical aminocaproic acid (RR 0.48, 95% CI 0.20 to 1.10) in two trials with 131 participants. We assessed the certainty of the evidence as low. Systemic tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (RR 0.33, 95% CI 0.21 to 0.53) in seven trials with 754 participants, as did aminomethylbenzoic acid (RR 0.10, 95% CI 0.02 to 0.41), as reported in one study. Evidence to support an associated reduction in risk of complications from secondary hemorrhage (i.e. corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no evidence of an effect on the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose.  The number of days for the primary hyphema to resolve appeared to be longer with the use of systemic aminocaproic acid compared with no use, but this outcome was not altered by any other intervention. The available evidence on usage of systemic or topical corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials. We found no evidence of an effect between a single versus binocular patch on the risk of secondary hemorrhage or time to rebleed. We also found no evidence of an effect on the risk of secondary hemorrhage between ambulation and complete bed rest.

AUTHORS' CONCLUSIONS

We found no evidence of an effect on visual acuity of any of the interventions evaluated in this review. Although the evidence was limited, people with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhage. However, hyphema took longer to clear in people treated with systemic aminocaproic acid. There is no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphema, other than possibly to reduce the rate of secondary hemorrhage. The potentially long-term deleterious effects of secondary hemorrhage are unknown. Similarly, there is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions (such as patching, bed rest, or head elevation) in the management of traumatic hyphema. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.

Epidemiology and outcomes of hyphema: a single tertiary centre experience of 180 cases

PURPOSE

To characterize the epidemiology and outcomes of hyphema.

METHODS

Retrospective case series. Medical records from patients with traumatic and spontaneous hyphema seen at the Wilmer Eye Institute, Johns Hopkins, from 2011 through 2017 were evaluated. Aetiology, demographics, clinical characteristics, complications, management and outcomes were ascertained. Multivariable logistic regression was used to identify factors associated with elevated intraocular pressure (IOP), rebleeding and poor outcome (final visual acuity ≤ 20/40) in traumatic hyphema. A safe frequency of follow-up was retrospectively determined.

RESULTS

Traumatic hyphema (n = 152) was more common in males (78%) and adults (55%), with sports/recreational activities being the most frequent cause (40%). Elevated IOP was the most common complication (39%). Rebleeding occurred in seven patients (5%) and was more likely with a higher IOP on presentation (OR:1.1; p = 0.004). Thirty-seven patients (24%) had a poor outcome, mostly due to traumatic sequelae such as cataract (32%) or posterior segment involvement (30%). A poor outcome was more likely with worse presenting visual acuity (OR: 9.1; p = 0.001), rebleeding (OR: 37.5; p = 0.035) and age > 60 years (OR: 16.0; p = 0.041). Spontaneous hyphema (n = 28) did not have a gender predominance and was more common in adults > 60 years (71%). The most common cause was iris neovascularization (61%). Complications and visual outcomes were worse compared with traumatic hyphema.

CONCLUSIONS

Traumatic hyphema continues to be common in young males engaging in sports, necessitating increased awareness for preventive eyewear. Older age and rebleeding can lead to poor outcomes. Elevated IOP at presentation predisposes to rebleeding and warrants frequent follow-up. Otherwise, routine follow-up at days 1, 3, 5, 7 and 14 is sufficient for uncomplicated cases.

Medical interventions for traumatic hyphema

BACKGROUND

Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of vision. Associated trauma (e.g. corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may seriously affect vision. Such complications can lead to permanent impairment of vision. People with sickle cell trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates and severity of complications increase.

OBJECTIVES

To assess the effectiveness of various medical interventions in the management of traumatic hyphema.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); MEDLINE Ovid; Embase.com; PubMed (1948 to June 2018); the ISRCTN registry; ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The date of the search was 28 June 2018.

SELECTION CRITERIA

Two review authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included randomized and quasi-randomized trials that compared various medical (non-surgical) interventions versus other medical intervention or control groups for the treatment of traumatic hyphema following closed-globe trauma. We applied no restrictions regarding age, gender, severity of the closed-globe trauma, or level of visual acuity at the time of enrollment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data for the primary outcomes, visual acuity and time to resolution of primary hemorrhage, and secondary outcomes including: secondary hemorrhage and time to rebleed; risk of corneal blood staining, glaucoma or elevated intraocular pressure, optic atrophy, or peripheral anterior synechiae; adverse events; and duration of hospitalization. We entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean differences (MD).

MAIN RESULTS

We included 20 randomized and seven quasi-randomized studies with a total of 2643 participants. Interventions included antifibrinolytic agents (systemic and topical aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest.We found no evidence of an effect on visual acuity for any intervention, whether measured within two weeks (short term) or for longer periods. In a meta-analysis of two trials, we found no evidence of an effect of aminocaproic acid on long-term visual acuity (RR 1.03, 95% confidence interval (CI) 0.82 to 1.29) or final visual acuity measured up to three years after the hyphema (RR 1.05, 95% CI 0.93 to 1.18). Eight trials evaluated the effects of various interventions on short-term visual acuity; none of these interventions was measured in more than one trial. No intervention showed a statistically significant effect (RRs ranged from 0.75 to 1.10). Similarly, visual acuity measured for longer periods in four trials evaluating different interventions was also not statistically significant (RRs ranged from 0.82 to 1.02). The evidence supporting these findings was of low or very low certainty.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (RR 0.28, 95% CI 0.13 to 0.60) as assessed in six trials with 330 participants. A sensitivity analysis omitting two studies not using an intention-to-treat analysis reduced the strength of the evidence (RR 0.43, 95% CI 0.17 to 1.08). We obtained similar results for topical aminocaproic acid (RR 0.48, 95% CI 0.20 to 1.10) in two studies with 121 participants. We assessed the certainty of these findings as low and very low, respectively. Systemic tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (RR 0.31, 95% CI 0.17 to 0.55) in five trials with 578 participants, as did aminomethylbenzoic acid as reported in one study (RR 0.10, 95% CI 0.02 to 0.41). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e. corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no evidence of an effect in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The number of days for the primary hyphema to resolve appeared to be longer with the use of systemic aminocaproic acid compared with no use, but this outcome was not altered by any other intervention.The available evidence on usage of systemic or topical corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no evidence of an effect between a single versus binocular patch or ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed.

AUTHORS' CONCLUSIONS

We found no evidence of an effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears that people with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema took longer clear in people treated with systemic aminocaproic acid.There is no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphema other than possibly to reduce the rate of secondary hemorrhage. Similarly, there is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions (such as binocular patching, bed rest, or head elevation) in the management of traumatic hyphema. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.

Controversies in the pathophysiology and management of hyphema

Traumatic hyphemas present dilemmas to physicians. There are numerous controversies pertaining to the optimal approach to traumatic hyphema and no standardized guidelines for its management. We address some of these controversies and present a pragmatic approach. We discuss various medical agents and surgical techniques available for treatment, along with the indications for their use. We address the complications associated with hyphema and how to diagnose and manage them and consider the management of hyphema in special situations such as in children and sickle-cell anemia and in rare clinical syndromes such as recurrent hyphema after placement of anterior chamber intraocular lenses.

Medical interventions for traumatic hyphema

BACKGROUND

Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of vision. Associated trauma (e.g. corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may seriously affect vision. Such complications may lead to permanent impairment of vision. Patients with sickle cell trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates and severity of complications increase.

OBJECTIVES

To assess the effectiveness of various medical interventions in the management of traumatic hyphema.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2013), EMBASE (January 1980 to August 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 30 August 2013.

SELECTION CRITERIA

Two authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included randomized and quasi-randomized trials that compared various medical interventions versus other medical interventions or control groups for the treatment of traumatic hyphema following closed globe trauma. We applied no restrictions regarding age, gender, severity of the closed globe trauma, or level of visual acuity at the time of enrolment.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data for the primary and secondary outcomes. We entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as odds ratios and continuous outcomes as mean differences.

MAIN RESULTS

We included 20 randomized and seven quasi-randomized studies with 2643 participants in this review. Interventions included antifibrinolytic agents (oral and systemic aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest. No intervention had a significant effect on visual acuity whether measured at two weeks or less after the trauma or at longer time periods. The number of days for the primary hyphema to resolve appeared to be longer with the use of aminocaproic acid compared with no use, but was not altered by any other intervention.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (odds ratio (OR) 0.25, 95% confidence interval (CI) 0.11 to 0.57), but a sensitivity analysis omitting studies not using an intention-to-treat (ITT) analysis reduced the strength of the evidence (OR 0.41, 95% CI 0.16 to 1.09). We obtained similar results for topical aminocaproic acid (OR 0.42, 95% CI 0.16 to 1.10). We found tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (OR 0.25, 95% CI 0.13 to 0.49), as did aminomethylbenzoic acid as reported in one study (OR 0.07, 95% CI 0.01 to 0.32). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e. corneal bloodstaining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no difference in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The available evidence on usage of corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no difference in effect between a single versus binocular patch or ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed.

AUTHORS' CONCLUSIONS

Traumatic hyphema in the absence of other intraocular injuries uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to permanent impairment of vision, especially in patients with sickle cell trait/disease. We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients treated with aminocaproic acid take longer to clear.Other than the possible benefits of antifibrinolytic usage to reduce the rate of secondary hemorrhage, the decision to use corticosteroids, cycloplegics, or nondrug interventions (such as binocular patching, bed rest, or head elevation) should remain individualized because no solid scientific evidence supports a benefit. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.

A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema

OBJECTIVE

To determine the safety and efficacy of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema.

DESIGN

Multicenter, randomized, double-masked, placebo-controlled clinical trial.

PARTICIPANTS

A total of 51 patients participated in this trial (power = 36%, 2-tailed test).

INTERVENTION

Patients presenting with traumatic hyphema were randomly assigned to 5-day treatment with topical aminocaproic acid or a placebo gel. Patients were monitored daily with ocular examination and vital sign testing for the 5 days of treatment and at 24 and 48 hours after treatment. General physical examination and laboratory testing were performed at baseline and day 5.

MAIN OUTCOME MEASURES

The main efficacy variable was the rate of rebleeding. Secondary efficacy variables included time to hyphema clearance, intraocular pressure, time to secondary hemorrhage, and visual acuity. Safety variables included adverse events, vital signs, and laboratory measurements.

RESULTS

Rebleeding occurred in 30% of the placebo group (8 of 27; 95% confidence interval [CI] = 14-50%), versus 8% of the treatment group (2 of 24; 95% CI = 1-27%), for an estimated continuity-corrected difference in percentage of patients with bleeding of 17% (95% CI = -3-38%). Secondary efficacy variables were similar in the groups, except that there was a trend towards more visual improvement in the topical aminocaproic acid group (54%) than in the placebo group (30%) at the last measurement (P = 0.08). Adverse events were similar.

CONCLUSIONS

This study provides evidence that topical aminocaproic acid is safe and demonstrates trends towards reducing the rebleeding rate in the management of traumatic hyphema. However, because the study was terminated before complete enrollment, more definitive recommendations will require a larger trial.

Outpatient management of traumatic microhyphema

OBJECTIVE

This study was performed to evaluate the clinical course of patients treated for traumatic microhyphema and the occurrence of elevated intraocular pressure (IOP) and secondary hemorrhage in these patients.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Records of all patients treated for traumatic microhyphema through the Wills Eye Hospital Emergency Department from January 1997 through September 1999 were analyzed retrospectively. Patients examined for 3 consecutive days after presentation and 2 weeks after initial presentation were included. Patients with open-globe injury were excluded. A total of 162 patients met the study criteria.

INTERVENTION

All patients were treated initially as outpatients according to the standard Wills Eye Hospital protocol for traumatic microhyphema (atropinization, bedrest, shield, restriction of antiplatelet medications). Three patients were subsequently hospitalized.

MAIN OUTCOME MEASURES

The occurrence of IOP elevation (greater than 21 mmHg) and rebleeding was recorded. The effect of topical corticosteroids was evaluated.

RESULTS

IOP was elevated in 14 patients. Six patients had IOP less than 26 mmHg and required no treatment. Six patients had IOP greater than 26 mmHg and received medical treatment. In two patients, IOP increased after initial presentation. Of 150 patients with normal IOP at presentation, only one (0.7%) developed an elevated IOP at any point to warrant treatment (28 mmHg). Rebleeding was documented in three patients, one of whom developed a layered hyphema. The incidence of rebleeding was not statistically associated with the use of topical corticosteroids.

CONCLUSIONS

Complications from traumatic microhyphema treated with standard measures are few. Closeness of follow-up may be determined by IOP on presentation. Secondary hemorrhage seems to be unaffected by the use of topical corticosteroids.

Management of traumatic hyphema

Hyphema (blood in the anterior chamber) can occur after blunt or lacerating trauma, after intraocular surgery, spontaneously (e.g., in conditions such as rubeosis iridis, juvenile xanthogranuloma, iris melanoma, myotonic dystrophy, keratouveitis (e.g., herpes zoster), leukemia, hemophilia, von Willebrand disease, and in association with the use of substances that alter platelet or thrombin function (e.g., ethanol, aspirin, warfarin). The purpose of this review is to consider the management of hyphemas that occur after closed globe trauma. Complications of traumatic hyphema include increased intraocular pressure, peripheral anterior synechiae, optic atrophy, corneal bloodstaining, secondary hemorrhage, and accommodative impairment. The reported incidence of secondary anterior chamber hemorrhage, that is, rebleeding, in the setting of traumatic hyphema ranges from 0% to 38%. The risk of secondary hemorrhage may be higher in African-Americans than in whites. Secondary hemorrhage is generally thought to convey a worse visual prognosis, although the outcome may depend more directly on the size of the hyphema and the severity of associated ocular injuries. Some issues involved in managing a patient with hyphema are: use of various medications (e.g., cycloplegics, systemic or topical steroids, antifibrinolytic agents, analgesics, and antiglaucoma medications); the patient's activity level; use of a patch and shield; outpatient vs. inpatient management; and medical vs. surgical management. Special considerations obtain in managing children, patients with hemoglobin S, and patients with hemophilia. It is important to identify and treat associated ocular injuries, which often accompany traumatic hyphema. We consider each of these management issues and refer to the pertinent literature in formulating the following recommendations. We advise routine use of topical cycloplegics and corticosteroids, systemic antifibrinolytic agents or corticosteroids, and a rigid shield. We recommend activity restriction (quiet ambulation) and interdiction of non-steroidal anti-inflammatory agents. If there is no concern regarding compliance (with medication use or activity restrictions), follow-up, or increased risk for complications (e.g., history of sickle cell disease, hemophilia), outpatient management can be offered. Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.

Comparison of tranexamic acid and prednisolone in the treatment of traumatic hyphema. A randomized clinical trial

OBJECTIVE

Oral antifibrinolytics, oral steroids, and no oral treatment are the preferred medical treatments for traumatic hyphema. Antifibrinolytics and steroids have decreased the chance of rebleeding in some studies but failed to alter the clinical course in others. Rate of secondary hemorrhage seems variable among different geographic and ethnic groups of patients. Comparison of the treatments in each population is necessary to document the most effective method of preventing recurrent hemorrhage.

DESIGN

Randomized, placebo-controlled, clinical trial.

PARTICIPANTS

Two hundred thirty-eight patients in whom hyphema developed after a blunt trauma entered the study.

INTERVENTION

Eighty patients received 75 mg/kg per day oral tranexamic acid (TA) divided into 3 doses, 80 patients received a placebo with the same number of tablets and frequency as those of the TA group, and 78 patients received 0.75 mg/kg per day oral prednisolone divided into 2 doses.

MAIN OUTCOME MEASURE

Secondary hemorrhage during the hospital course was measured.

RESULTS

Secondary hemorrhage occurred in 8 patients (10%) of the TA group, 14 patients (18%) of the prednisolone group, and 21 patients (26%) of the placebo group. The difference between the incidence of rebleeding between TA and placebo groups was statistically significant (P = 0.008). Patients receiving a placebo had a greater chance of secondary bleeding than did patients receiving TA (odds ratios = 3.2; 95% confidence interval = 1.3, 7.5). The incidences of rebleeding were not significantly different in placebo versus prednisolone groups (P = 0.21) and TA versus prednisolone groups (P = 0.15).

CONCLUSION

In a population with a high rate of secondary bleeding, TA is more effective than oral prednisolone or no oral treatment in preventing rebleeding among patients with traumatic hyphema.

An analysis of risk for secondary hemorrhage in traumatic hyphema

OBJECTIVE

Factors such as size of hyphema, intraocular pressure, initial visual acuity, and use of steroids or antifibrinolytic drugs may be associated with the likelihood of rebleeding in traumatic hyphema. The association of the visual outcome with secondary hemorrhage has been questioned.

DESIGN

Randomized, placebo-controlled, clinical trial.

PARTICIPANTS

Two hundred and thirty-eight patients who had hyphema develop after blunt trauma.

INTERVENTION

Eighty patients received oral tranexamic acid, 80 patients received placebo, and 78 patients received oral prednisolone.

MAIN OUTCOME MEASURES

Secondary hemorrhage and vision at the time of discharge from the hospital were measured.

RESULTS

Rebleeding occurred in 43 (18%) of the patients and was prevented significantly by oral tranexamic acid compared with the placebo (odds ratios [OR] = 0.39; 95% confidence interval [CI], 0.17, 0.89). Occurrence of secondary hemorrhage had weak associations with initial high intraocular pressure (OR = 2.7; 95% CI, 0.99, 7.3) and initial visual acuity of 6/60 or less (OR = 1.8; 95% CI, 0.9, 3.7). Secondary hemorrhage had no statistical association with age, gender, oral prednisolone, size of hyphema, and retinal damage. Visual acuity of 6/60 or less at the time of discharge was significantly associated with rebleeding (OR = 10.5; 95% CI, 3.7, 29.2), initial visual acuity of 6/60 or less (OR = 9.9; 95% CI, 2.8, 38.0), retinal damage (OR = 14.6; 95% CI, 3.8, 55.8), and male gender (OR = 6.5; 95% CI, 1.4, 31.9). Final visual acuity had no significant statistical association with age, use of oral prednisolone or tranexamic acid, and size of hyphema.

CONCLUSIONS

High intraocular pressure and low vision at the time of first examination may be associated with increased chance of rebleeding. Retinal damage, secondary hemorrhage, male gender, and initial poor vision are associated with a worse visual outcome in patients with traumatic hyphema.

Traumatic hyphema: outcomes of outpatient management

OBJECTIVE

This study aimed to compare the outcomes of outpatient and inpatient management of layered hyphema.

DESIGN

The charts of all patients with traumatic layered hyphema treated in the Massachusetts Eye and Ear Infirmary Emergency Ward between January 1991 and November 1995 were analyzed retrospectively. Patients with a diagnosis of microscopic hyphema, ruptured globe, or posterior segment injury other than commotio retinae on their initial emergency department visit were excluded. The study patients were compared with an historic control group of patients with hyphema who had been treated at the same institution from July 1986 to February 1989.

PARTICIPANTS

A total of 154 patients met the study criteria. These were compared with 119 patients in the historic control group.

INTERVENTION

Of the study patients, 5% were admitted on the day of presentation, 95% were treated initially as outpatients, and 4% subsequently were admitted. All of the patients in the historic control group were treated with initial hospital admission.

MAIN OUTCOME MEASURES

The rebleed rates of the study and control groups were compared. The final recorded visual acuity and causes of best-corrected visual acuity worse than 20/30 were analyzed for the study group.

RESULTS

The rebleed rates of the study group and the historic control group were 4.5% and 5.0%, respectively (P > 0.05). The rebleed rates of the study patients initially treated as outpatients and the historic control group were 3.4% and 5%, respectively (P > 0.05). The rebleed rates of study patients who did not receive aminocaproic acid and the subset of historic control patients who received aminocaproic acid were 3.3% and 4.8%, respectively (P > 0.05). Ninety-six percent of study patients achieved a final best-corrected visual acuity of 20/30 or better. Causes of a final documented visual acuity worse than 20/30 included loss of patient follow-up before resolution of the hyphema, traumatic cataract, macular hole, and macular degeneration.

CONCLUSIONS

In the authors' predominantly white patient population, close outpatient follow-up of traumatic hyphemas appears to be safe and effective. Hospitalization for hyphema does not appear to decrease the rate of rebleeding. Decreased vision in the setting of traumatic hyphema generally results from comorbidities not affected by inpatient management.

Sickle cell trait as a risk factor for secondary hemorrhage in children with traumatic hyphema

PURPOSE

To determine risk factors for secondary hemorrhage and poor visual outcome in children with traumatic hyphemas.

METHODS

We reviewed 99 eyes of 97 children younger than 18 years who had been hospitalized for hyphema within 48 hours of blunt eye trauma. Inpatient records were examined for race, age, sickle cell trait status, size of hyphema and intraocular pressure at admission, secondary hemorrhage (rebleed of hyphema), and medications while hospitalized. Fifty-five eyes of 53 children had at least 1 month of follow-up or attained best-corrected visual acuity of 20/50 or better at their last outpatient visit.

RESULTS

Among 99 eyes of 97 children with traumatic hyphema, secondary hemorrhage occurred in nine eyes (9%). Among 72 eyes of 70 African-American children, secondary hemorrhage occurred in nine eyes (14%), whereas in 27 eyes of 27 white children, there were no secondary hemorrhages. However, when the 14 eyes of 13 sickle cell trait-positive children were excluded from the African-American group, the 57 eyes of sickle cell trait-negative African-American and white children did not have any secondary hemorrhages. The sickle cell trait-positive group had secondary hemorrhages in nine of 14 eyes (64%), significantly (P < .005) different from the 0% rate in the 57 eyes of African-American sickle cell trait-negative and white children. The sickle cell trait-positive group also had higher intraocular pressure and permanent visual impairment.

CONCLUSION

Sickle cell trait is a significant risk factor for secondary hemorrhage, increased intraocular pressure, and permanent visual impairment in children who have traumatic hyphemas following blunt trauma.

Secondary hemorrhage in traumatic hyphema. Predictive factors for selective prophylaxis

BACKGROUND

Treatment to decrease the rebleeding rate in traumatic hyphema remains controversial. Although antifibrinolytics recently have been shown to reduce secondary hemorrhage rates, their routine use has not been widely applied because of adverse side effects and the relatively low frequency of severe hyphema complications. Alternatively, their use may be restricted to patients at high risk, but prognostic factors for rebleeding have not been clearly identified.

METHODS

From a prospective ocular trauma survey, 371 patients with traumatic hyphema were identified, and Fisher's exact test was applied to test for significant differences between patients who did and did not rebleed for various characteristics. Significant factors contributing to rebleeding were fitted into a multiple logistic regression model, and odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Secondary hemorrhage occurred in 8% of patients and was significantly more frequent in those with visual acuities of 20/200 or less (OR = 3.1; 95% CI = 1.3,7.5), initial hyphema more than one third of the anterior chamber (OR = 2.8; 95% CI = 0.9,8.0), delayed medical attention more than 1 day after injury (OR = 2.9; 95% CI = 1.0,8.4), and elevated intraocular pressure at time of first examination (OR = 2.9; 95% CI = 1.1,7.9). The secondary hemorrhage rate rose from 5% without any of these specified factors to 15% with at least one factor present. No statistical associations were found for age, injury-related iris abnormalities, or aspirin usage.

CONCLUSION

Using multivariate logistic regression in populations with low rates of secondary hemorrhage, a predictive model may be used to categorize patients who have higher rebleeding rates, for whom possible benefits may outweigh the risks of prophylactic treatment, and those with lower rebleeding rates, who may not necessarily benefit from treatment.

Meta-analysis of systemic anti-fibrinolytics in traumatic hyphaema

We report a meta-analysis of randomised, controlled, clinical trials of systemic anti-fibrinolytics in traumatic hyphaema. Outcome measures were rate of secondary haemorrhage and final visual acuity. An estimate of the overall odds ratio for each outcome measure was calculated both by combining the logarithms of the odds ratios, and by the Mantel-Haenszel method. The results confirm a beneficial effect of systemic antifibrinolytics on the rate of secondary haemorrhage, but not on final visual acuity.

Urban eye trauma. A one-year prospective study

PURPOSE

The authors conducted a 1-year prospective study investigating the demographics, causation, and treatment of eye trauma in an urban population at one medical center.

METHODS

All patients sustaining eye injuries who were evaluated by the ophthalmology service over a 1-year interval were included. A formal questionnaire was completed with demographic data and details of the injury being obtained. An ophthalmologic examination was performed on each patient, and examination findings, diagnostic tests obtained, diagnosis, and treatment were recorded and analyzed.

RESULTS

This study included 584 eye injuries. Three hundred seventy-one injuries (70%) occurred in males and 159 (30%) in females. The average age was 30.5 years; 110 (21%) patients were pediatric. Sixty-two percent of all patients presented within 24 hours of their injury. Thirty-seven percent of all injuries occurred in the street, 31% at home, and only 13% at the workplace. For those older than 65 years of age, 48% of injuries were the result of a fall. Sixty percent of all eye injuries were caused by blunt trauma. Only 42 (8%) patients wore eye wear at the time of their injury. Diagnoses and management were recorded.

CONCLUSIONS

The inner city population is more likely to sustain eye trauma as the result of an assault and is less likely to be involved in a work- or sports-related injury. Given poor compliance with outpatient management and follow-up, aggressive primary management may be indicated to optimize visual outcome.