Hyphema eye paracentesis (Video)

This video shows an eye with a large hyphema (blood) inside the anterior chamber. The blood has settled into the bottom 35% of the eye, while the upper portion of the AC is dense with free-floating RBCs. In the last half of the movie, I create a paracentesis using a super-blade scalpel.

Hyphemas typically occur secondary to blunt trauma, and occasionally after surgery. They will absorb eventually, but the concerns in the immediate post-bleed period is:

1. Pressure: The blood clogs up the trabecular meshwork and the pressure can become very high in the eye, and compromise the optic nerve. Treat aggressively with aqueous supressants (beta-blockers) and perform a paracentesis if needed.
2. Blood staining: If the pressure is too high for two long, the inner cornea can be stained with blood. This staining may go away after years, but it can take a long time and affect vision. Decrease the pressure, and perform an AC washout if staining seems imminant.

A couple more points

  • Avoid CAIs in anyone who might be sickle-cell as this acidifies the AC and promotes sickling
  • If you’re going to use an oral CAI, use methazolamide instead as it affects the pH less
  • The re-bleed danger time is 3-5 days as this is when the clot retracts. Follow daily during this time period to watch the pressure
  • A paracentesis can lower the pressure acutely, but may also cause a rebleed as the pressure that was tamponading the bleed is lowered suddenly
  • Don’t gonio these eyes until everything has resolved to avoid rebleeding. Many of these eyes will have angle recession from the blunt trauma that may cause glaucoma down the road

Download this video

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hyphemaparacentesis.wmv (13.7 meg, Windows video file)

Screencaptures

Hyphema
This photo shows an eye filled with blood. Specifically, the anterior chamber is full of heme, so much that the RBCs have settled in the bottom 40% of the chamber. The upper chamber is still full of sangre, such that no details of the underlying iris can be seen.
Hyphema staining
One thing to watch for with large hyphemas like this one is corneal blood staining. The high ocular pressure can push RBC products into the corneal stroma and stain it red, reducing visual potential. This stain usually goes away, but perhaps not for a long time. Large hyphemas with high pressure may thus be an indication for an anterior chamber washout.
 Paracentesis eye
In this case, a super-blade was used to create a tract into the ac. The advantage of a superblade over a needle is the control, the self-sealing wound, and ease of burping through the same site on repeat visits.
Burping the wound
This closeup photo of the cornea shows a paracentesis site at the limbus that is being “burped” to decrease the eye pressure. This eye is suffering from very high glaucoma pressure secondary to a hyphema.
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Dr. Timothy Root is a practicing ophthalmologist and cataract surgeon in Daytona Beach, Florida. His books, video lectures, and training resources can be found at:

6 COMMENTS

  1. the day after cateract surgery a young doctor burped my eye because the pressure was too high. I would like to know if a puncture was made and if the proceedure was necessary. I do not have glacoma.

    • I’m just an OD student, but I believe the doctor just put pressure on you eye to “burp” it. Excess fluid came out of the existing incision from the cataract surgery. Those incisions are small which are self sealing (no stitches typically) but can be temporarily forced open with enough pressure that soon after surgery.

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