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Hyphema – Blood in the Eye Explained

A hyphema is a collection of blood in the anterior chamber of the eye, most often caused by trauma. Prompt medical evaluation is essential to protect vision.

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Things worth knowing about "Hyphema"

A hyphema is a collection of blood in the anterior chamber of the eye, most often caused by trauma. Prompt medical evaluation is essential to protect vision.

What Is a Hyphema?

A hyphema refers to the accumulation of blood in the anterior chamber of the eye – the fluid-filled space between the cornea and the iris. The blood typically originates from torn blood vessels in the iris or the ciliary body. Depending on the extent of the bleeding, the anterior chamber may be partially or completely filled with blood. A completely blood-filled anterior chamber is known as a total hyphema or “8-ball hyphema.”

Causes

The most common cause of a hyphema is blunt trauma to the eye, such as injuries sustained during sports, physical altercations, or motor vehicle accidents. Other possible causes include:

Penetrating eye injuries (e.g., from sharp objects)
Postoperative bleeding following eye surgery (e.g., cataract surgery)
Coagulation disorders or anticoagulant medications (e.g., warfarin, aspirin)
Sickle cell disease
Iris neovascularization (rubeosis iridis) associated with diabetes or other conditions
Ocular tumors (rare)

Symptoms

Common signs and symptoms of a hyphema include:

A visible red or dark red layer of blood in the eye
Blurred vision or partial to complete vision loss (depending on the size of the bleed)
Eye pain or a sensation of pressure
Sensitivity to light (photophobia)
Elevated intraocular pressure, which raises the risk of glaucoma

Grades of Severity

Hyphema is clinically classified into four grades:

Grade I: Blood fills less than one-third of the anterior chamber
Grade II: Blood fills between one-third and one-half of the anterior chamber
Grade III: Blood fills more than half, but not the entire anterior chamber
Grade IV: Total hyphema (entire anterior chamber filled with blood)

Diagnosis

Diagnosis is typically made by an ophthalmologist using the following methods:

Slit-lamp examination: Detailed assessment of the anterior chamber and the extent of bleeding
Tonometry: Measurement of intraocular pressure to detect potentially dangerous elevations
Fundoscopy: Examination of the posterior segment to identify associated injuries
Imaging (ultrasound, CT scan): Used when additional ocular or orbital injuries are suspected

Treatment

Treatment depends on the grade of the hyphema and any associated conditions:

Conservative Management

Bed rest with the head elevated at approximately 30 degrees to encourage blood settling
Eye protection using a shield or protective glasses
Eye drops to lower intraocular pressure (e.g., beta-blockers, carbonic anhydrase inhibitors)
Corticosteroid eye drops to reduce inflammation
Avoidance of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), which increase bleeding risk

Surgical Treatment

If intraocular pressure remains elevated, if corneal blood staining is at risk of occurring, or if the blood does not reabsorb adequately, surgical intervention may be required. This typically involves anterior chamber washout (irrigation) to remove the accumulated blood.

Complications

Without appropriate management, hyphema can lead to serious complications:

Secondary glaucoma due to obstruction of aqueous humor drainage
Corneal blood staining from hematin deposits, causing corneal opacity
Rebleeding, which is most likely to occur within the first 3 to 5 days
Permanent vision loss

References

Yanoff M, Duker JS. Ophthalmology. 5th ed. Elsevier; 2019.
Walton W, Von Hagen S, Grigorian R, Zarbin M. Management of traumatic hyphema. Survey of Ophthalmology. 2002;47(4):297–334.
American Academy of Ophthalmology. Hyphema – Preferred Practice Pattern. AAO Guidelines; 2021. Available at: https://www.aao.org

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