November 2010

 

COVER FEATURE

 

Anterior Segment Trauma

Treating closed globe injuries


by Michelle Dalton EyeWorld Contributing Editor

   

How to manage the accompanying hyphema varies depending upon size, IOP, and sickle cell disease

Hyphema Source: Picture depot

Hyphema is a fairly common occurrence after someone sustains a closed globe injury. As a result of the ocular trauma and hyphema, spikes in IOP are also relatively common; usually, the larger the hyphema, the greater the risk of IOP elevation. In the short term, managing the hyphema is of the utmost importance, and experts say treatment varies based on several issues: how long the IOP remains elevated, re-bleeding, whether or not there is corneal bloodstaining, and whether or not the patient is a carrier for (or has) sickle cell disease. "Anyone who might be a carrier for sickle cell has a much higher risk of permanent damage to the eye after a hyphema," said Morton Goldberg, M.D., Joseph Green Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore. In any kind of blunt trauma (closed globe), "the acute phase is where you worry most about the direct effect of the blood on the outflow system of the eye," said Robert J. Noecker, M.D., M.B.A., vice chair, University of Pittsburgh Medical Center Eye Center, Pittsburgh. "You've got blood issues in the short term. The more blood that is present, the more likely you're going to intervene. The critical five-day mark is when the chances of a re-bleed are decreased." In general, if half the anterior chamber is filled with blood in cases of hyphema, glaucoma develops in roughly 25% of those eyes, according to Deepak Gupta, M.D., in a chapter from his book Glaucoma: Diagnosis and Management.

In pediatric patients with closed globe injuries, "amblyopia is a potential complication of a large or slow-clearing hyphema, especially in children under the age of 4," said Angela Turalba, M.D., glaucoma specialist and attending, Massachusetts Eye and Ear Infirmary, Boston. "It depends on how long it takes the hyphema to clear and how big it is initially," she said. "A general rule of thumb is the younger the patient and the larger the hyphema, the higher the risk of developing amblyopia."

In the overwhelming majority of cases, the hyphema clears on its own within a week or so, and doing "nothing" may be the best treatment strategy, said Iqbal (Ike) K. Ahmed, M.D., assistant professor, University of Toronto, Toronto, and clinical assistant professor, University of Utah, Salt Lake City.

Overall concerns

Blunt trauma "leads to early and long-term risk," Dr. Ahmed said. "In the early post-injury phase, our main concern is red blood cell glaucoma, where the red blood cells block the trabecular meshwork. In the longer term, a main concern is ghost-cell glaucoma where denatured red blood cells and by-products clog up the meshwork." The latter can develop "weeks to months" after a hemorrhage, he said. Any sign of angle recession will also increase the risk for glaucoma development, he said. "The degree of the angle recession doesn't correlate to the risk for development," Dr. Ahmed said. "Generally speaking, though, the prognosis is pretty good."

Dr. Ahmed prefers a "very conservative" management strategy in general, with an emphasis on treating hyphema medically rather than surgically. "Once you decide to operate on the eyes, you've increased the risk of re-bleeding," he noted. If the IOP cannot be managed medically over a longer period of time (more than a week), he then considers surgery.

In addition to medically managing hyphemas, Dr. Turalba's treatment strategy is to keep patients on bed rest or limited activity, and to instruct patients to avoid using anti-inflammatory agents such as nonsteroidals, which might exacerbate bleeding. "Re-bleeds can occur in up to 33% of patients," Dr. Turalba said. "They're typically worse than the initial bleed."

Dr. Goldberg said all hyphema-related glaucoma should be treated initially with beta blockers. "Other things can be done, but none of the recommendations for treatment have been proven in a clinical trial. We treat based on clinical guidelines, not 'hard and fast' rules," he said. He avoids using prostaglandins as they may cause additional inflammation; "corticosteroids by mouth or via eyedrops are also said to lower inflammation, but we don't have proof that they work." To prevent a secondary hemorrhage, Dr. Goldberg suggests using epsilon-aminocaproic acid (Amicar, Xanodyne Pharmaceuticals, Newport, Ky.), but side effects such as nausea, vomiting, or syncope may render it unsuitable in some patients. Hyphema can be microscopic, "where there's no layering, or a visible clot at the bottom." Size can also vary from 10% of the anterior chamber to 100% of the chamber, Dr. Goldberg said.

"The more blood there is, the more dangerous the hyphema tends to be. You usually won't have corneal staining involving the visual axis of the cornea unless the hyphema is fairly large," he said.

Although re-bleeds typically occur 3 to 5 days after the initial trauma (the re-bleed is likely a result of lysis of the clot within damaged blood vessels), they can occur at any time; 5 to 30% will have a secondary hemorrhage and "then visual acuity may be affected. A minority of patients may have permanent loss of vision," Dr. Goldberg said. A primary concern for physicians should be to immobilize the iris and ciliary body (through the use of atropine) and introduce a steroid to counteract the inflammation, Dr. Noecker said. If the blunt trauma results in angle recession glaucoma, the IOP "may never come down. The trabecular meshwork can only heal in one way, by creating scar tissue. Over the long term, the trabecular meshwork becomes hyalinized and this changes the meshwork anatomically and increases the loss of outflow. Those situations are very difficult to manage medically," he said.

"Cycloplegia limits the movement of the iris and helps prevent formation of synechiae," Dr. Turalba said. Amicar "has shown to reduce the incidence of re-bleeds, but it can have the side effect of postural hypotension." If she deems it necessary to surgically intercede, Dr. Turalba will perform an anterior chamber washout and will quickly opt for that if there is any sign of corneal blood staining. She added she is more likely to intervene surgically if the patient is a child, or if the patient has sickle cell disease. "In children, I have seen corneal blood staining occur at lower pressures compared to adults," Dr. Turalba said. Anecdotally, she's seen corneal blood staining in children whose pressures have never been documented to be above 30 mm Hg.

Patients with hyphema can have angle closure from pupil block or peripheral synechiae, Dr. Ahmed said. "Our goals are to prevent negative results for these patients."

Sickle cell complications

For those with sickle cellor the sickle cell traitDr. Goldberg advocates a much lower threshold for reducing an IOP elevation. "My guideline for decompressing the anterior chamber of sicklers by paracentesis is 24 mm Hg or greater for any consecutive 24-hour period," he said. "Ideally, you should measure IOPs in this group every six hours. Performing a paracentesis to lower the IOP is recommended if the ocular hypertension doesn't resolve on its own. I use the '24 for 24' rule: IOP needs to be 24 mm Hg or less for 24 hours to eliminate my concerns."

Dr. Noecker explained that sickle cell patientsor "sicklers"are at a disadvantage because the cells are rigid. The cells attempt to leave the eye through the meshwork, which is difficult to the sickling; it is more likely that aqueous outflow will eventually become blocked. This in turn makes sicklers more prone to IOP spikes.

"You probably don't want to treat these patients with systemic carbonic anhydrase inhibitors [CAIs], as it will make them metabolically more acidic, which can make it more likely the cells will sickle and cause an IOP spike. "If they re-bleed, then I'll more likely consider a surgical intervention. I prefer to wait and watch the higher pressure in a previously normal eye. Sometimes the slightly higher IOP can help prevent a re-bleed," Dr. Noecker said. Dr. Noecker will tolerate IOPs in this group up to about 30 mm Hg before considering more aggressive therapy mainly because people with hyphema tend to be "younger, active patients without glaucoma."

Dr. Goldberg suggests determining sickle status in every hyphema patient, even those who look Caucasian. "Even a minimal to moderate increase in IOP for a short period of time in sicklers can lead to permanent loss of vision, such as from optic atrophy," he said. "A child may look Caucasian, but if he or she is a carrier or has the homozygenous sickle cell anemia genes, the child is at a much higher risk of losing vision from blunt trauma with hyphema."

Although most of the time he manages conservatively, Dr. Ahmed said there remains some debate on how to treat sicklers, "but in general I don't have any magic solution for carriers. Sicklers will have more aggressive glaucoma, so managing the IOP spike and inflammation is a bit more critical," he said. Initially, he'll start a course of steroids and topical glaucoma medications beginning first with beta blockers, then adding alpha agonists, and CAIs if necessary. He warns against using Diamox (acetazolamide, Duramed, Cincinnati) in sicklers, as it can have the opposite effect and raise pressure instead of lowering it. "It's a potent pressure-lowering drug, but not for sicklers," he said. Dr. Turalba said she's "much more aggressive with sicklers" in her management strategy. "In sicklers, if the IOP is in the high 20s for more than a day, I'm more likely to perform an AC washout," she said. "In general, you should start to consider washout or more aggressive medical therapy. This group can shoot up quickly and you need to watch them carefully."

In the short term, sicklers will "almost always spike," Dr. Noecker said, and added he has seen sicklers with IOPs as high as 60 mm Hg following blunt trauma. He will tolerate a spike as high as 30 mm Hg "if it's only for a day or so; it'll probably come down. If there is a family history of glaucoma, I'm also quicker to intervene."

For Dr. Ahmed, an IOP of more than 30 will lead to more aggressive treatment if the patient is a sickler. He typically performs a lavage and paracentesis, and possibly an iridectomy, "if I couldn't get all the blood out with other methods," he said. "Some do suggest a trab with washout unless there's a known history of glaucoma and the patient has already suffered visual field loss. Whether I'd insert a tube or a shunt is debatable, but I lean toward favoring shunts."

Dr. Turalba said, "Angle recession can accompany a hyphema. When the hyphema clears and angle recession is noted for more than 180 degrees, the risk of developing glaucoma increases to about 9 to 10%. Half of those who develop glaucoma in the injured eye may then develop glaucoma in the fellow eye," regardless of sickle cell status. This is why she emphasizes long-term follow-up in patients who suffer blunt trauma to the eye.

Non-sickler treatment strategies

In non-sicklers, Dr. Goldberg will tolerate "much higher" levels of IOP spikes, as normal eyes "can withstand higher pressure better than those with sickle cell," he said. "Non-sicklers with pressure elevations should be treated initially with anti-glaucoma eyedrops."

Likewise, Dr. Ahmed is "not overly excited if pressures are in the 20s if they're non-sicklers," he said. "I start to get concerned if the pressure rises to the 30s or 40s." At that point, the risk of central retinal vein occlusion and corneal bloodstaining increases. If the patient's pressure rises to even the 40s or 50s, "I'll tolerate it for up to a week. Longer than that is an indication to operate if the pressure doesn't come down."

Other concerns in non-sicklers that may lead to surgical intervention: 8-ball hyphema and the patient can't see anything for a week, posterior synechiae, etc. If there is no sign of bloodstaining, just watch it, the physicians recommended. In non-sicklers, the aim is to prevent bloodstaining, optic atrophy, and peripheral anterior synechiae, Dr. Goldberg said. He'll perform a paracentesis if the IOP is more than 35 mm Hg for seven days, or if IOP is 50 mm Hg or more for five days, he said. To prevent anterior synechiae, "I'd operate at day five for an extensive hyphema regardless of IOP," he said. "A normal eye can take a fair amount for a day, even more," Dr. Noecker said. "Those patients can be treated aggressively with medicine." If the pressure remains high and is not showing signs of coming back down, "we'll try topical beta blockers, CAIs, and alpha agonists but might have to intervene surgically."

Dr. Ahmed recommends bed rest, but patient compliance is an issue in that area depending on age. "I don't harp on it," he said. "Oral steroids can be a controversial management strategy as well. I don't have a clear preference for or against, but there is some suggestion that they can create anti-fibrolytic properties."

Down the road

Hyphema can be implicated in "so many thingsangle recession alone with no glaucoma may create weak zonules, which may affect cataract surgery down the road," Dr. Ahmed said. "The reality is most people with angle recession don't develop glaucomafewer than 20%. It's important to look at everything in the eye, from front to back."

Once someone has had a closed globe injury, "he is a potential glaucoma patient for the rest of his life," Dr. Noecker said. "We won't know if there's damage until we can document changes. For better or worse, though, the effects of hyphema-related blunt trauma have been relatively well worked out over the decades. We know they need to be followed, we know they potentially have a poor long-term prognosis, etc."

Follow-up should be intense in the first week, regardless of the presence of sickle cell disease, Dr. Turalba said. "After the first week or so, you can spread out visits, depending on how well the hyphema clears and what the eye pressure is. Any time there is a hyphema, you need to rule out other ocular injuries, including occult ruptured globes, traumatic cataracts, or any retinal detachment." Especially in the emergency room setting, "it's easy to concentrate on just the hyphema, but occasionally additional imaging is needed to assess the orbit and the back of the eye."

Editors' note: The physicians interviewed for this article have no financial interests related to their comments.

Contact information

Ahmed: 416-25-3937, ike.ahmed@utoronto.ca
Goldberg: 410-955-6846, mgoldbrg@jhmi.edu
Noecker: 412-526-1757, noecrj@upmc.edu
Turalba: 617-901-0686, angela_turalba@meei.harvard.edu

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