Patients may present with blurred vision, pain, photophobia and tearing following blunt, concussive injury to the eye or orbit. Hyphemas (blood in the anterior chamber) are described by the amount of anterior chamber (AC) they occupy !rade " # less than one$%uarter of the visible volume of the AC !rade & # one$%uarter to one$half of the visible volume of the AC !rade ' # one$half to three$%uarters of the visible volume of the AC !rade ( # complete filling of the visible AC )he term *eight$ball hemorrhage* is reserved for completely filled anterior chambers with blac+$colored clots. PATHOPHYSIOLOGY )here are two suggested mechanisms of hyphema formation. ,ither direct, contusive forces cause mechanical tearing of the fragile blood vasculature of the iris and-or angle, or concussive trauma creates rapidly rising intravascular pressure within these vessels, resulting in rupture. .lood in the AC is not by itself necessarily harmful. However if %uantities are sufficient it may obstruct the outflow of a%ueous humor, resulting in glaucoma. Hemolytic glaucoma results from direct obstruction of the trabecular meshwor+ by fresh blood. Hemosiderosic glaucoma results from trabecular meshwor+ obstruction from degrading hemoglobin. !host cell glaucoma results from trabecular meshwor+ obstruction by the s+eletons of the disintegrating red blood cells. /inally, any e0ternal force strong enough to produce internal bleeding is also sufficiently strong to produce direct damage to the adjacent trabecular meshwor+, resulting in sluggish a%ueous drainage (late glaucoma). MANAGEMENT A thorough history is critical. Circumstances surrounding the event, current medicines and previous ocular history are important pieces of data. .leeding in the eye warrants %uestioning concerning systemic blood disorders such as sic+le cell anemia, hemophilia and 1on 2illebrand3s disease (vascular hemophilia). 4f the patient is a poor historian or %uestions arise regarding systemic health, order systemic tests for sic+le cell anemia (sic+le prep or sic+le de0) and bleeding disorders (P) and P))). 5cular e0amination should include an evaluation of the adne0a (6$ray, C) scan to rule out fracture or entrapment) cornea (to rule out perforation), sclera (to rule out ruptured globe), anterior chamber, lens, vitreous and retina. 4f a clear view of the fundus is obstructed by the hyphema or vitreous hemorrhage, perform or refer for a .$scan ultrasound of the globe. 2hether these individuals should be hospitali7ed is controversial. 8ost practitioners manage uncomplicated hyphemas (grade ") without hospital admission. Cycloplege the patient with atropine "9 .4:-;4: and prescribe a steroid such as Pred /orte or 1e0ol ;&H-;4:. 4f intraocular pressure is above &<mm Hg, it should be controlled using topical beta$bloc+ers .4:. 2hen 45P re%uires acute attention (i.e., over '=mm Hg) prescribe aceta7olamide =>>mg P5 .4:, barring systemic contraindications, until the pressure is ade%uately controlled. 4f there are corneal epithelial defects, ?0 a topical antibiotic prophylactically. 4nstruct the patient to limit activity to the bathroom and bed rest, laying with the head elevated at an angle of '> degrees. Provide an eye shield for additional protection. )o prevent re$bleeding, use only acetaminophen to manage pain@ avoid aspirin and ibuprofen. ?eferral for surgical evaluation is indicated if there is corneal blood staining, if 45P is greater than A>mm Hg, if there is an eight$ball hemorrhage or if the 45P remains above '= for seven days. /ollow up with 1A, slit lamp, 45P and dilated fundus e0am for four consecutive days, then as necessary. CLINICAL PEARLS !onioscopy is contraindicated because it increases the ris+ of re$bleeding. However, up to => percent of patients with hyphema possess angle recession and the possibility of developing a secondary traumatic late glaucoma. 8onitor the 45P of these patients regularly. )he onset of secondary glaucoma is between "& months and => years. Perform gonioscopy after the event has resolved and the ris+ of re$bleeding has passed. Aminocaproic acid (Amicar =>mg-+g), an antifibrinolytic, has been advocated by some to reduce the ris+ of re$bleeding. 5ne of its potential side effects is severe nausea and vomiting, a contraindication in patients with hyphema. )he medicine seems to function best in children but is not universally accepted and remains controversial. http--cms.revoptom.com-handboo+-sect(f.htm