What Is a Hyphema?

After a ball, fist, or airbag hits the eye, patients notice the colored part looks 'filled with blood' or see a red line pooling at the bottom of the eye, and it is frightening. They want to know what that blood means, whether it will clear, and how serious it is, especially since the eye can ache and the vision can be hazy.

The anterior chamber is normally filled with clear fluid that drains out through a filter at the angle where the iris meets the cornea. In a hyphema, blunt force tears small vessels of the iris or ciliary body, and blood escapes into that fluid. Because blood is heavier than the fluid, it settles into a visible layer when you are upright, which is why sitting up with the head raised helps it collect low and clear.

The blood itself will usually reabsorb, but the risks come from what it does meanwhile. Red cells and debris can clog the drainage angle and drive up eye pressure, which if severe and prolonged can damage the optic nerve. And the injured vessel can bleed again as the clot breaks down, often around days three to five, sometimes filling more of the chamber than before. Those two risks, pressure and rebleeding, are why a hyphema is watched closely rather than left alone.

Most hyphemas follow blunt trauma, a sports ball, a fist, an elbow, a paintball, an airbag, but they can also occur after surgery or from abnormal vessels in the eye. They are graded by how much of the anterior chamber the blood fills, from a thin layer to a chamber that is completely full (a 'total' or 'eight-ball' hyphema), with higher grades carrying more risk to pressure and vision.

The course runs over several days to two weeks as the blood clears. The critical window for a rebleed is roughly the first several days, as the initial clot retracts. Elevated eye pressure can appear early or later from blood clogging the drain. Patients with sickle cell trait or disease are especially vulnerable: their red cells sickle in the low-oxygen environment of the anterior chamber, block the drain more easily, and tolerate high pressure poorly, so even a small hyphema is managed carefully. A significant hyphema also means the eye took enough force to warrant checking for angle damage that can raise pressure years later.

A hyphema is already urgent; seek care immediately, and treat these as red flags of a worsening problem:

• Severe or increasing eye pain, or pain with nausea and vomiting, which can signal a dangerous pressure spike.
• Vision that is getting worse, or blood that is filling more of the eye (a rebleed).
• A new headache or halos around lights with the painful eye.
• Known sickle cell trait or disease, or use of blood thinners, which raise the risk.
• Any hyphema at all, because it needs prompt examination and cannot be safely judged at home.

The doctor measures vision and examines the eye at the slit-lamp to grade how much blood is in the chamber and to look for other trauma to the iris, lens, and cornea. Eye pressure is measured, and rechecked over the following days because pressure can climb as the eye clears. The pupil is dilated when safe to examine the retina for accompanying injury, and gonioscopy, a lens that views the drainage angle, may be done later to check for angle recession once the eye has settled. Sickle cell status is checked in at-risk patients, and CT imaging is added if the mechanism suggests a fracture or a ruptured globe.

The foundation is rest with the head of the bed elevated so the blood settles and clears, along with a rigid eye shield and limited activity to reduce the chance of a rebleed. A dilating drop keeps the eye comfortable and steadies the iris, and a topical steroid calms inflammation. If eye pressure rises, pressure-lowering drops or pills are used; pressure control is especially aggressive in sickle cell patients, in whom certain drops are avoided. Blood thinners and strenuous activity are held. Most hyphemas clear with this approach, but a chamber that stays full, an uncontrolled pressure, or blood staining the cornea may require surgery to wash out the blood.

• Do not carry on normal activity; genuine rest with the head elevated is part of the treatment.
• Do not lift, bend, strain, or exercise, which can trigger a rebleed.
• Do not take aspirin or other blood-thinning pain relievers unless your doctor specifically approves them.
• Do not rub, press on, or remove the eye shield except as instructed.
• Do not skip the follow-up visits; the pressure checks and rebleed watch over the next several days are the whole point.

A hyphema needs to be seen the same day. Call May Eye Care Center right away after any blunt eye injury that leaves blood in the eye, or go to an emergency room if severe pain, vomiting, or rapidly worsening vision suggests a pressure spike. Patients in the Hanover area can reach the office to arrange the prompt exam and the close follow-up a hyphema requires over the first days.

A hyphema is blood in the front chamber of the eye after blunt trauma, and because of the risk of pressure spikes and rebleeding it needs same-day care, rest with the head elevated, a protective shield, and close monitoring.