Hyphaema

Hyphaema is blood in the space between the cornea and iris. It most often follows blunt trauma that tears vessels in the iris or ciliary body, but blood can also appear after surgery, with abnormal new vessels or with a bleeding disorder. A visible inferior level may be easy to recognise; a microhyphaema requires slit-lamp identification of red cells suspended in the aqueous. The amount present should be described reproducibly, including height or approximate fraction of the chamber. A completely blood-filled chamber can obscure other important findings.

The first assessment must establish whether the eye wall is intact. Hyphaema after a sharp injury, a distorted pupil, a shallow chamber or extensive haemorrhage can coexist with an open globe. Protect and refer that injury before performing pressure measurements. In a closed-globe injury, assess acuity, pupils, corneal clarity, pressure and the posterior segment when visible. Lens displacement, traumatic cataract, retinal injury and orbital fractures may need separate management. Avoid gonioscopy, scleral indentation and unnecessary compression while the fresh injury is vulnerable.

Red cells and inflammatory debris can obstruct aqueous drainage and raise intraocular pressure. Pressure may change as blood clears or rebleeds, and a comfortable patient with a small initial collection is not guaranteed a benign course. Sickle cell disease and trait are particularly important because red cells can sickle within the anterior chamber and obstruct drainage; optic nerve perfusion may be compromised at pressures that other patients might tolerate better. Ask about known status and family history, and use clinically appropriate testing with specialist advice rather than judging risk from appearance alone.

Treatment is individualised and the evidence that any single intervention improves final visual acuity is limited. A clear protective shield and restriction of strenuous activity reduce opportunities for further injury. Many services advise sleeping with the head elevated and avoiding lifting or straining; the precise activity period should be written in the discharge plan. Topical corticosteroid and cycloplegic treatment may be selected for accompanying inflammation and photophobia. These treatments do not replace repeated pressure assessment or investigation of a new fall in sight.

The cited NHS Greater Glasgow and Clyde pathway considers prednisolone acetate 1% up to six times daily and cyclopentolate 1% three times daily for uveitis or photophobia, with review and adjustment. Pressure treatment depends on the level, trend, comorbidity and response. Beta blockers need respiratory and cardiac precautions, and carbonic anhydrase inhibitors require particular judgement in sickling disorders. Do not apply a generic pressure ladder to a patient with sickle cell disease or trait without senior advice. Admission may be needed for a large collection, uncontrolled pressure, a bleeding disorder or inability to attend close review.

Surgical evacuation is considered when pressure remains uncontrolled, corneal blood staining develops or a large collection fails to clear. Thresholds differ with duration, extent and individual vulnerability; the specialist must integrate these factors rather than use one isolated number. Once the acute collection has resolved, gonioscopy and posterior segment assessment help identify angle recession and other occult damage. Angle-related glaucoma can emerge much later, so apparent early recovery should lead into a clearly specified longer-term pressure surveillance plan.