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
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hyphemaparacentesis.wmv (13.7 meg, Windows video file)