163

Saudi Journal of Ophthalmology, Volume 20, No. 3, July September 2006

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
H
yphema, the presence of blood in the anterior
chamber (AC), is a common indication for emer-
gency admission after an eye injury. Most cases of
hyphema are the result of concussive injury to the an-
terior segment of the eye, which causes bleeding from
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 usu-
ally resolves rapidly without significant sequel. The op-
timal management of traumatic hyphema (TH) sec-
ondary to blunt, non-penetrating ocular trauma re-
mains controversial
1-6
and vary from one institution to
another.

Various therapeutic modalities, including
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: 00965-
7402891; Fax: 00965-4811314; Email: sidky@hotmail.com
164
Saudi Journal of Ophthalmology, Volume 20, No. 3, July September 2006
patching, sedation, bed rest and various pharmacologi-
cal 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 phar-
macological agents is superior to others, in the treat-
ment of non-complicated TH. Patients with TH sus-
tained 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 ex-
ceed 50% of the anterior chamber i.e. only grades 1
and 2. Traumatic hyphema of grade 3 and 4 were ex-
cluded (Table 1). Children less than 7 years old, pa-
tients with microscopic hyphema or those associated
with other ocular injuries were excluded. Table 2 illus-
trates a summary of inclusion and exclusion criteria.
All patients were presented in the same day of trauma
and no medications were given before their presenta-
tion.
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 pa-
tients were actually assigned to. All patients were in-
structed 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. Fun-
dus 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 dis-
charged 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%) respec-
tively 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 (ste-
roid only), 28 (70%) patients had a BCVA of <0.3 log
Hyphema Grade Volume of Hyphema/Volume of AC
1 <1/3
2 1/3 - 1/2
3 1/2 - <Total
4 Total
Table 1. Grading of Hyphema
a i r e t i r C e d u l c n I e d u l c x E
e g A s r a e y 7 s r a e y 7 <
r e d n e G e l a m e f r o e l a M
m e l b o r p e y e s u o i v e r P e n o N e s a e s i d r a l u c o a r t n I
y r e g r u s r a l u c o a r t n I
s m e l b o r p c i m e t s y S e n o N r e d r o s i d g n i d e e l B
n o i s n e t r e p y H
s u t i l l e m s e t e b a i D
a m u a r T y r u j n i t n u l B g n i t a r o f r e P
g n i t a r t e n e P
n o i t a t n e s e r p t a n o i s i V 0 0 2 / 0 2 n a h t r e t t e B e s r o w r o 0 0 2 / 0 2
P O I g H m m 2 2 g H m m 0 3 >
C A y l n o a m e h p y H n o i t r o t s i d r o j a M
a i h c e n y s r o i r e t n A
t n e m g e s r o i r e t s o P l a m r o N y g o l o h t a P
a m e h p y H s s e l r o C A f o % 0 5 % 0 5 >
Table 2. Criteria of the Patients
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Saudi Journal of Ophthalmology, Volume 20, No. 3, July September 2006
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 differ-
ence 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 respec-
tively. 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 (ste-
roid 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 2
nd
day, completely re-
solved on the 5
th
day and ended with FVA of 20/30
without any complications.
During the follow-up period all patients recov-
ered 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 cata-
ract 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 subse-
quently a clot. Blood re-enters the circulation as a whole
red blood cells by passing through the trabecular mesh-
work 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 trabe-
cular meshwork so red blood cells (7 microns) pass
readily. In addition a small amount of haemolysed de-
bris is absorbed through the iris vessels. Injury to a
blood vessel wall exposes collagen, and vessel contrac-
tion 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 pro-
vide evidence that no statistically significant difference
exists among patients treated by eye patching and se-
dation and those without patching or sedation.
2, 10
El-
evating the head of the bed to 30
o
to 45
o
facilitates set-
tling 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 subse-
quent slit-lamp examinations.
11
Various topical medications have been recom-
mended for the treatment of TH, including steroids
l a t o T 1 p u o r G
) y l n o d i o r e t s (
2 p u o r G
) o l c y c d i o r e t s (
3 p u o r G
) l o r t n o c (
r e b m u N 0 2 1 0 4 0 4 0 4
) s r a e y ( e g n a R e g A
n a e M
D S
7 4 - 7
9 . 7 1
5 3 . 3 1
7 4 - 7
6 . 2 2
1 3 . 4 1
5 3 - 7
4 1
2 6 . 8
7 4 - 7
1 . 7 1
2 0 . 1 1
e l a M x e S
e l a m e F
0 1 1
0 1
1 e d a r G e d a r G
2 e d a r G
) % 6 . 1 5 ( 2 6
) % 4 . 8 4 ( 8 5
) % 5 5 ( 2 2
) % 5 4 ( 8 1
) % 5 5 ( 2 2
) % 5 4 ( 8 1
) % 5 4 ( 8 1
) % 5 5 ( 2 2
R A M g o l 3 . 0 A V I
R A M g o l 3 . 0 >
R A M g o l n a e M
) % 3 . 3 6 ( 6 7
) % 7 . 6 3 ( 4 4
9 2 . 0
) % 0 7 ( 8 2
) % 0 3 ( 2 1
2 . 0
) % 5 6 ( 6 2
) % 5 3 ( 4 1
3 . 0
) % 5 5 ( 2 2
) % 5 4 ( 8 1
9 3 . 0
R A M g o l 3 . 0 A V F
R A M g o l 3 . 0 >
R A M g o l n a e M
) % 7 . 6 9 ( 6 1 1
) % 3 . 3 ( 4 0
6 0 . 0
) % 0 9 ( 6 3
) % 0 1 ( 4 0
1 . 0
) % 0 0 1 ( 0 4
0 0 0 0 0
5 0 . 0
) % 0 0 1 ( 0 4
0 0 0 0 0
5 3 0 . 0
e m i t n o i t p r o s e R
) s y a d (
e s i r P O I
1 . 4
) % 6 . 1 1 ( 4 1
) % 3 . 3 ( 4 0
2 . 4
) % 5 2 ( 0 1
) % 5 ( 2 0
9 . 3
) % 5 ( 2 0
0 0
2 . 4
) % 5 ( 2 0
) % 5 ( 2 0
Table 3. Comparison between the Three Groups
166
Saudi Journal of Ophthalmology, Volume 20, No. 3, July September 2006
and cycloplegics for the treatment of traumatic
iridocycilitis.
4,12
Other studies found that topical medi-
cations, 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 diag-
nosed 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 an-
terior (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 Ku-
wait, we are probably fortunate enough to have the
luxury of admitting these cases. Our study was a pro-
spective 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 monitor-
ing become much easier, and the risk of amblyopia
much reduced. We also focused on simple non-com-
plicated 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 re-
ceived. 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 develop-
ment 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 topi-
cal steroids. Steroid induced cataract usually takes few
months to occur.
15
It is reported that cataract attribut-
able 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) de-
veloped traumatic cataract. This lower rate in our study
is probably due to our selection of the relatively mod-
erate trauma not causing hyphema greater than grade
2. A rise in IOP can occur in the acute or chronic set-
ting following injury. Elevated IOP occurs in 24% -
32% of all traumatic hyphemas.
10
There are several pro-
posed mechanisms for this acute rise in IOP: red blood
cells, platelets, and fibrin can block the trabecular
meshwork. The outflow tract may be directly dam-
aged 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 at-
tributed to the fact that we limited our study to the
small traumatic hyphema (< 50%). Including bigger
size traumatic hyphema may have increased the fig-
ure. 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 sig-
nificant and clinically easily controlled, but certainly
interesting to notice. It has been demonstrated in pro-
spective clinical trials that topical steroids must often
be administered over weeks before ocular hyperten-
sion 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 immedi-
ately 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
Differ-
ences 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 re-
ported 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
Vari-
ous studies have suggested treatment regimes directed
towards the prevention of secondary haemorrhage, in-
cluding 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 oc-
cupying more 50 % of the anterior chamber and not
associated with significant collateral eye injury over
167
Saudi Journal of Ophthalmology, Volume 20, No. 3, July September 2006
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. How-
ever, we definitely can say that patients on placebo treat-
ment did not do any worse. This observation is inter-
esting 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.
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