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Original Article Traumatic Hyphema Comparison between Different Treatment Modalities

Abdulmutalib H. Behbehani, MD, FRCSC, Sidky M. A. Abdelmoaty, MD, FRCS (Glasgow), Adel Aljazaf, MD, FRCS

Abstract Background: This prospective, randomised study was performed to determine the best treatment available for mild noncomplicated traumatic hyphema. Method: This study comprised 120 patients who fulfill the criteria of our study. The patients were admitted in our center through the eye casualty department and they were randomly divided into three equal and similar groups, one group received Predforte eye drops, the other received Predforte and Cyclogel 1% eye drops and the control group received Tears Natural eye drops. For each patient, the following characteristics were recorded at presentation: age, sex, size of hyphema, initial visual acuity (IVA), intraocular pressure (IOP) and fundus examination. The outcome, hyphema resorption time, and occurrence of complications such as rebleeding and secondary glaucoma were recorded and compared between the groups. Results: The resorption time was almost the same (4 days) regardless of the treatment modality the patient received. Four (3.3%) patients developed a rebleed, two (5%) in the first (steroid only) group and 2 (5%) in the third (control) group. The final visual acuities (FVA) were < 0.3 log MAR in all (100%) the patients in the second (steroid cyclo) and third (control) groups, the mean log MAR is 0.05 and 0.035 in the second and third group respectively. However in the first (steroid only) group 36(90%) patients had FVA of < 0.3 log MAR and 4 (10%) had FVA > 0.3 log MAR on discharge, the mean log MAR is 0.1.P value of (0.04). The cause of the decline in final visual acuity in these 4 patients was the development of traumatic cataract rather than the treatment used. A total of 14 patients (11.6 %) developed a mild to moderate elevation of IOP (23-29 mmHg); 10 (25%) in the first (steroid only) group, 2 (5%) in the second (steroid cyclo) group and 2 (5%) in the third (control) group. In all cases, the IOP returned to normal either without treatment or with short term Timolol eye drops. Conclusion: In cases of mild simple traumatic hyphemas not exceeding 50%, simple lubricating drops probably is most efficient and safe treatment. Using other drops such as Predforte and Cyclopentolate did not have any addional beneficiary effect. Key Words: traumatic hyphema, rebleed, cataract

yphema, the presence of blood in the anterior chamber (AC), is a common indication for emergency admission after an eye injury. Most cases of hyphema are the result of concussive injury to the anterior segment of the eye, which causes bleeding from

From the Department of Surgery, Ophthalmology Division, Faculty of Medicine, Kuwait University, Albahar Eye Center, Kuwait. Correspondence to Sidky M.A. Abdelmoaty, MD, FRCS (Glasgow), Albahar Eye Center, PO Box 1059, Salmia 22011, Kuwait. Telephone: 009657402891; Fax: 00965-4811314; Email: sidky@hotmail.com

the root of the iris near the AC angle or in some cases haemorrhage from the ciliary body. Hyphema has a clinical course that may range from uneventful and mild inconvenience to devastating downhill course that may end with blindness or loss of the eye. However, it usually resolves rapidly without significant sequel. The optimal management of traumatic hyphema (TH) secondary to blunt, non-penetrating ocular trauma remains controversial1-6 and vary from one institution to another. Various therapeutic modalities, including

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patching, sedation, bed rest and various pharmacological agents have been used but no general agreement as to the best method of treatment has been agreed upon.

MATERIAL AND METHODS This is a prospective and randomised study that we performed to determine if the use of certain pharmacological agents is superior to others, in the treatment of non-complicated TH. Patients with TH sustained after a blunt injury were admitted to Al-Bahar Eye Center (ABEC) in Kuwait city through the eye casualty between August 2001 and July 2002. Patients were included in the study if they were older than 7 years old, with blunt injury only, and had no previous eye or systemic diseases. The hyphema should not exceed 50% of the anterior chamber i.e. only grades 1 and 2. Traumatic hyphema of grade 3 and 4 were excluded (Table 1). Children less than 7 years old, patients with microscopic hyphema or those associated with other ocular injuries were excluded. Table 2 illustrates a summary of inclusion and exclusion criteria. All patients were presented in the same day of trauma and no medications were given before their presentation. Once the patient is admitted to the ward, he will be randomly assigned to one of three pharmacological treatment regimens. The first treatment modality was Predforte (1%) eye drops (Allergan, Ireland) 4 times a day, ( Steroid only group); the second modality of treatment was Predforte (1%) eye drops 4 times a day and Cyclogel 1% eye drops (Alcon, Belgium) 3 times a day, (Steroid cyclo group); and the third one received Tears Natural eye drops (Alcon, Belgium) 4 times a day, (Control group). The observing ophthalmologist was masked from the type of treatment that the patients were actually assigned to. All patients were instructed to observe bed rest and reduce the physical activity to the minimum. They were also instructed to keep the head of the bed elevated. Eye pads were not used.

The visual acuity (VA) and intraocular pressure (IOP) were recorded on admission and discharge. Fundus examination and gonioscopy were performed whenever possible and only when felt easily feasible. The patients were closely observed for complications such as secondary bleeding or shooting up of the IOP during the course of the treatment. Patients were discharged once the hyphema cleared out completely and have no complications. The hyphema resorption time was recorded. They were followed-up one week, one month and 6 months after discharge. The drops that patient was receiving were tapered and stopped within one week of discharge.

RESULTS A total of 120 patients were enrolled in the study, their age ranged between 7 and 47 years with mean age of 17.9 years and SD. of 13.35 years. 110(91.7%) were male and 10 were female (M: F = 11:1), Table 3. The three groups were similar in terms of number included, age and grade of hyphema (Table 3). There were 40 patients in each group. The mean age of the first group was 22.6 14.31 years, the second group was 14 8.62 years and the third group was 17.11 11.02 years. The size of the TH was grade 1 in 22(55%) patients and grade 2 in 18(45%) patients in the first and second groups and 18 (45%) and 22(55%) respectively in the third group, chi-square showed P value of (0.586). The initial visual acuities (IVA) were nearly the same between the three groups. In the first group (steroid only), 28 (70%) patients had a BCVA of <0.3 log

Table 2. Criteria of the Patients

Criteria Age Gender Previous eye problem Systemic problems Include 7 years Male or female None None Intraocular disease Intraocular surgery Bleeding disorder Hypertension Diabetes mellitus Perforating Penetrating 20/200 or worse >30 mmHg Major distortion Anterior synechia Pathology >50% Exclude <7 years

Table 1. Grading of Hyphema Hyphema Grade 1 2 3 4 Volume of Hyphema/Volume of AC <1/3 1/3 - 1/2 1/2 - <Total Total

Trauma Vision at presentation IOP AC Posterior segment Hyphema

Blunt injury Better than 20/200 22 mmHg Hyphema only Normal 50% of AC or less

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minimum angle of resolution (log MAR) and 12 (30 %) had a BCVA between >0.3 1.0 log MAR. this group showed a mean IVA of 0.2 log MAR. In the second group (steroid cyclo), 26(65%) patients had a BCVA of < 0.3 log MAR, 14(35%) had a BCVA of >0.3 1.0 log MAR and the mean IVA of this group is 0.3 log MAR. In the third group (the control), 22(55%) patients had a BCVA of < 0.3 log MAR and 18 (45%) had a BCVA between >0.3 1.0 log MAR. the mean log MAR of the control group was 0.39. The difference was not significant, P value (0.366). The final visual acuities (FVA) were < 0.3 log MAR in all (100%) the patients in the second (steroid cyclo) and third (control) groups, the mean log MAR was 0.05 and 0.035 in the second and third group respectively. However in the first (steroid only) group 36(90%) patients had FVA of < 0.3 log MAR, as 4 (10%) patients of this group had FVA > 0.3 log MAR on discharge, the mean log MAR was 0.1. Chi-Square, one degree of freedom method showed P value of (0.04) between the control and the steroid only group. The cause of the decline in final visual acuity in these 4 patients was the development traumatic cataract. The hyphema resorption time was 3.9 days in the second (steroid cyclo) group, and 4.2 days in first (steroid only) and third (control) groups. A total of 14 patients (11.6 %) developed a mild to moderate elevation of IOP (23-29 mmHg) while in the hospital; 10 (25%) in the first (steroid only) group, 2 (5%) in the second (steroid cyclo) group and 2 (5%) in the third (control) group. Patients who developed moderate (26-29 mmHg) rise in the IOP were treated with Timolol maleate eye drops (Merk Sharp & Dhme BV, USA) twice a day and discontinued when the hyphema resorbs and IOP return to normal.

Four (3.3%) patients in our study developed a rebleed, 2 (5%) patients in the first (steroid only) group, one of them was grade 1 hyphema and the other was grade 2. In the third (control) group, 2 (5%) patients developed rebleeding, both of them showed grade 2 hyphema. All occurred on the 2nd day, completely resolved on the 5th day and ended with FVA of 20/30 without any complications. During the follow-up period all patients recovered completely without any sequel related to the hyphema. However, the four patients who were already noticed to develop traumatic cataract while in patient, continued to have poor vision (BCVA of 20/100) at their last follow-up and they were scheduled for cataract surgery.

DISCUSSION Traumatic hyphema is a common sequel of a blunt injury; the blood circulates in the AC and then settles inferiorly in the AC to form a fluid level and subsequently a clot. Blood re-enters the circulation as a whole red blood cells by passing through the trabecular meshwork and schlemms canal and into the aqueous veins within the sclera before passing to the episcleral veins. Particles up to 12 microns can pass through the trabecular meshwork so red blood cells (7 microns) pass readily. In addition a small amount of haemolysed debris is absorbed through the iris vessels. Injury to a blood vessel wall exposes collagen, and vessel contraction and platelet adhesion enable a temporary clot to form at the site of the injury. Extrinsic and intrinsic coagulation pathways are stimulated and during the next 2 to 5 days clot retraction at the site of injury can cause secondary haemorrhage.1-2 Traditionally TH patients have been hospitalized for 5 to 7 days for treatment.7, 8, 9 Several studies provide evidence that no statistically significant difference exists among patients treated by eye patching and sedation and those without patching or sedation.2, 10 Elevating the head of the bed to 30o to 45o facilitates settling of the hyphema in the inferior AC and aids in classifying the hyphema. Inferior settling also facilitates more rapid improvement of VA, early evaluation of the posterior pole, and greater clearing of the AC angle. Also a better estimate of the decrease or increase in the amount of blood in the AC is possible during subsequent slit-lamp examinations.11 Various topical medications have been recommended for the treatment of TH, including steroids

Table 3. Comparison between the Three Groups

Tot al N u m b er A ge Range (years) M e an SD M a le F e m a le 120 7-47 17.9 13.35 110 10 62 (51.6% ) 58 (48.4% ) 76 (63.3% ) 44 (36.7% ) 0.29 116 (96.7% ) 04 (3.3% ) 0.06 4.1 14 (11.6% ) 04 (3.3% ) 22 (55% ) 18 (45% ) 28 (70% ) 12 (30% ) 0.2 36 (90% ) 04 (10% ) 0.1 4.2 10 (25% ) 02 (5% ) 22 (55% ) 18 (45% ) 26 (65% ) 14 (35% ) 0.3 40 (100% ) 00000 0.05 3.9 02 (5% ) 00 18 (45% ) 22 (55% ) 22 (55% ) 18 (45% ) 0.39 40 (100% ) 00000 0.035 4.2 02 (5% ) 02 (5% ) G roup 1 (st eroi d onl y) 40 7-47 22.6 14.31 G roup 2 (st eroi d cycl o) 40 7-35 14 8.62 G roup 3 (cont rol ) 40 7- 47 17.1 11.02

Se x

G ra d e G ra d e 1 G ra d e 2 IV A 0.3 lo g M A R > 0.3 lo g M A R M e a n lo g M A R 0.3 lo g M A R > 0.3 lo g M A R M e a n lo g M A R

F VA

Reso rp tio n tim e (d ays) IO P rise

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and cycloplegics for the treatment of traumatic iridocycilitis.4,12 Other studies found that topical medications, including steroids and cycloplegics are not necessary because of the lack of definite evidence of therapeutic advantages.6,10,13 Other actually found that cycloplegics can be hazardous because acute glaucoma may be precipitated in a patient with previously diagnosed narrow AC angle.14 Topical use of steroids after the fourth or fifth day of retained hyphema may be advantageous to decrease the associated iridocyclitis and to prevent or deter the development of peripheral anterior (PAS) synechia or posterior synechia.11 Most cases of non complicated traumatic hyphema in most centres around the world are managed and treated on an outpatient basis, most probably because of economic and cost efficiency causes. Here, in Kuwait, we are probably fortunate enough to have the luxury of admitting these cases. Our study was a prospective one so allowed us to monitor these patients closely. We restricted our study to patients aged 7 years or older as controlling physical activity and monitoring become much easier, and the risk of amblyopia much reduced. We also focused on simple non-complicated traumatic hyphema to reduce the effects of other injuries on the measured outcome. Hyphema greater than 50% was also excluded as they obscure evaluation of further injuries on initial examination. Microscopic hyphema was also excluded, as objective evaluation may be less definite. The resorption time was almost the same (4 days) regardless of the treatment modality the patient received. While all patients in the different groups had similar initial visual acuity IVA, Four patients (10%) of those who received steroids only had poorer final visual acuity FVA (< 20/40) on discharge. The cause of decrease vision in those patients was the development of cataract. The speed of the development (within days of trauma) and the type of cataract (cortical and anterior sub-capsular) were more suggestive of trauma as the cause of the cataract rather than the use of topical steroids. Steroid induced cataract usually takes few months to occur.15 It is reported that cataract attributable to blunt trauma occurred in 24.5% of the cases and only 15.4% of them will have significant cataract that will need cataract extraction. In our study, 10% in the first (steroid only) group (3.3% in all patients) developed traumatic cataract. This lower rate in our study is probably due to our selection of the relatively moderate trauma not causing hyphema greater than grade 2. A rise in IOP can occur in the acute or chronic setting following injury. Elevated IOP occurs in 24% -

32% of all traumatic hyphemas.10 There are several proposed mechanisms for this acute rise in IOP: red blood cells, platelets, and fibrin can block the trabecular meshwork. The outflow tract may be directly damaged from the blunt injury. Pupillary block may also be a consideration, especially with large clots. Finally, steroid-induced glaucoma is a potential mechanism.17 In our study the incidence of acute mild to moderate raise in the IOP was (11.6%), which is much lower than the reported figures. This difference can be attributed to the fact that we limited our study to the small traumatic hyphema (< 50%). Including bigger size traumatic hyphema may have increased the figure. The rise of the IOP was associated more with the steroid only group (group1) compared to the others. This observation, even though was statistically not significant and clinically easily controlled, but certainly interesting to notice. It has been demonstrated in prospective clinical trials that topical steroids must often be administered over weeks before ocular hypertension develops and that with increasing topical steroid dose the IOP elevation becomes more pronounces.18,19 Blunt ocular trauma, on the other hand, may cause transient or permanent high IOP, occurring immediately or in time after the injury.20 Hence, we think that the transient rise in IOP in our patients was due to blunt trauma rather than steroid induced. The low rate of rebleeding is reported in our study (3.3%) is comparable to other studies, which showed a rebleed rate to be as low as 2.4% to as high as 38%.21,22 Higher estimates in general derived from studies performed in the united states,23 and lower estimates from those performed elsewhere.21 Differences in the racial make-up of the study populations may explain these discrepancies; black patients have been found to rebleed more frequently than whites in some mixed population studies.24 Some studies reported that the size of hyphema on presentation did not influence the probability of secondary haemorrhage.21 Others have noted an increased risk of rebleeding in patients with larger hyphemas.25 Various studies have suggested treatment regimes directed towards the prevention of secondary haemorrhage, including topical steroids and cycloplegics.2 In our study we did not find any statistically significant difference between the three groups in term of the rate of rebleeding. We did not find any advantage of using topical steroids in cases of traumatic hyphema that is not occupying more 50 % of the anterior chamber and not associated with significant collateral eye injury over

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using placebo tears drops. Actually some of those who received topical steroid only actually developed (lens changes) and rise in the IOP more than the others. We can not, of course, conclude that these complications occurred because of the use of the topical steroids as they are more likely related to the trauma itself. However, we definitely can say that patients on placebo treatment did not do any worse. This observation is interesting and should be considered in managing these cases even though was not statistically significant.

CONCLUSION AND RECOMMENDATION In cases of mild simple traumatic hyphemas not exceeding 50%, simple lubricating drops probably is efficient and enough treatment, other modalities were not superior and probably no as safe.

REFERENCES
1. Wison FM. Traumatic hyphema. Pathogenesis and management. Ophthalmology 1980;87:910-919. 2. Read J, Goldberg MF. Comparison of medical treatment for traumatic hyphema. Trans Am Acad Ophthalmol Otolaryngol 1974;78:799-815. 3. Ohrstrom A. Traumatic hyphema with corticosteroids and mydriatics. Acta Ophthalmol (Copenh) 1972;50:549-554. 4. Gilgert HD, Jensen DA. Atropine in the treatment of traumatic hyphema. Ann Ophthalmol 1973;5:12971300. 5. Goldberg MF. Antifibrinolytic agents in the management of traumatic hyphema. Arch Ophthalmol 1983;101:1029-1030. 6. Spoor TC, Hammer M, Belloso H. Traumatic hyphema. Failure of steroids to alter its course: a double-blinded prospective study. Arch Ophthalmol 1980;98:116-119. 7. Clluom RD Jr, Chang B, eds. The Wills Eye Manual: office and emergency room diagnosis and treatment of eye disease. Philadelphia: Lippincott, 1994; pp 489. 8. Edward WC, Layden WE. Traumatic hyphema. A report of 184 consecutive cases. Am J Ophthalmol 1973;75:110-116. 9. Darr JL, Passmore JW. Management of traumatic

hyphema. Am J Ophthalmol 1967;63:134-136. 10. Crouch ER Jr, Williams PB. Trauma and bleeding. In: Tasman W, Jaeger EM, eds. Duanes Clinical Ophthalmology. Philadelphia: JB Lippincott; 1993;4:1-18. 11. Earl R, Crouch ER Jr. Management of traumatic hyphema: therapeutic options. J Pediatr Ophthalmol & Strabismus 1999;36:238-250. 12. Spaeth FL, Levy PM. Traumatic hyphema. Am J Ophthalmol 1966;62:1098-1106. 13. Crouch ER. Traumatic hyphema. J Pediatr Ophthalmol & Strabismus 1986;23:95-97. 14. Katzung BG: Cholinoceptor-blocking drugs, in Katzung BG (ed): Basic and clinical pharmacology (ed 6).Norwalk, CT, Appleton and Lange, 1995:102-105. 15. Bilgihan K, Gurelik G, Akata F, Hasanreisoglu B. Fluorometholone-induced cataract after photorefractive keratectomy. Ophthalmologica 1997;211(6):394-396. 16. Canavan YM, Archer DB. Anterior segment consequences of blunt ocular injury. Br J Ophthalmol 1982;66(9):549-555. 17. Eric G, Mead. The management of traumatic hyphema. (Journal article. Review. Review, Academic) International Ophthalmology Clinics. 1994;34(3):1-7. 18. Skuta GL, Morgan RK. Coricosteroid-induced glaucoma. In: Ritch R, Shields MB,Krupin T, eds. The glaucomas. St. Louis, Mo: Mosby-Year Book Inc; 1996:11771188. 19. Armaly MF. Corticosteroid glaucoma. In: Cairns JE,ed.Glaucoma.London, England: Grune& Stratton;1986:697-710. 20. Stefan C, Radulescu D, Cucea R, Nicolae A, Musat A, Balas M. Postcontusion glaucoma. Oftalmologia. 2000;52(3):41-43. 21. Lawrence T, Wilson D, Harvey J: The incidence of secondary haemorrhage after traumatic hyphema. Ann Ophthalmol 1990;22:276-278. 22. Thomas MA, Parrish RK, Feuer WJ: Rebleeding after traumatic hyphema. Arch Ophthalmol 1986;104:206210. 23. Kennedy RH and Brubaker RF: Traumatic hyphema in a defined population. Am J Ophthalmol 1988;106:123130. 24. Spoor TC, Kwitko GM, OGray JM, Ramocki JM: Traumatic hyphema in an urban population. Am J Ophthalmol 1990;109:23-27. 25. Witteman GJ, Brubaker SJ, Jahnson M, Marks RG: The incedence of rebleeding in traumatic hyphema. Ann Ophthalmol 1985;17:525-529.

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