Hyphema

What is hyphema?

Hyphema is the medical term for blood collecting in the front (anterior) chamber of your eye. The blood pools in the space right in front of your iris, the ring of muscle tissue that gives your eye its color.

If small, your ophthalmologist may only be able to see hyphema during an eye exam. But you can see medium-sized hyphemas without special tools. They usually look layered. Older, darker blood settles at the bottom. And newer, brighter blood settles at the top.

If you see a hyphema in your own eye or the eye of a child you care for, you should seek emergency medical care. But with prompt care, most cases of hyphema need only simple treatment like medications and rest.

How bad (severe) is it?

Experts grade hyphema based on how much bleeding there is. The higher the grade, the more severe the hyphema is and the higher the risk of complications. The grading system is as follows:

• Grade 0 (also known as microhyphema). No blood layering, but blood is visible, though it might require special tools to see.
• Grade 1. Layered blood that fills less than one-third of your anterior chamber.
• Grade 2. Layered blood filling one-third to one-half of your anterior chamber.
• Grade 3. Layered blood that fills at least one-half of your anterior chamber but doesn’t fill it completely.
• Grade 4 (total hyphema). Layered, dark red or black blood completely fills your anterior chamber. They’re sometimes called eight-ball or blackball hyphemas. This puts you at much higher risk for angle-closure glaucoma.

What are the symptoms of hyphema?

Symptoms of hyphema include:

• Blood pooling between your cornea and iris at the front of your eye.
• Blurred or distorted vision.
• Acting tired or sleepy (this is usually in younger children, and it’s also a potential symptom of head injuries).
• Nausea and vomiting (this can mean pressure inside your eye is dangerously high).

Eyelid swelling — although not a symptom of hyphema itself — is also common after injuries that cause hyphema.

If you sustain an injury and notice any of the above symptoms, seek care at your nearest emergency room.

What causes the condition?

Hyphema commonly happens with eye injuries, eye diseases and a few potential medical causes. These include:

• Sports-related injuries (especially those with smaller objects like balls or pucks, but also possible in boxing or fencing).
• Guns, including air guns, paintball guns, pellet guns and BB guns.
• Car crashes.
• When something sharp punctures your eye (penetrating injury).
• When a stretchy or elastic object — like a bungee cord — snaps back and hits your eye (recoil injury).
• Sickle cell disease.
• Hemophilia.
• von Willebrand disease.
• Leukemia.
• Different forms of diabetes or connected conditions like diabetes-related retinopathy and neovascularization of the eye.
• Eye cancers, especially ocular melanoma.
• Eye surgery, especially ones that treat iris and ciliary body-related conditions and issues.
• Medications like blood thinners (anticoagulants).

What are the risk factors for hyphema?

There are two main risk factors for hyphema:

• Age. About 70% to 75% of injury-related hyphema cases happen in children and young adults. The highest risk is between ages 10 and 20. Noninjury-related hyphema is more common in adults, especially above age 50.
• Sex. People assigned male at birth (AMAB) are much more likely to have hyphema. Experts estimate that their risk is three to five times higher than people assigned female at birth (AFAB).

What are the complications of this condition?

The most common complications with hyphema include:

• Ocular hypertension. Blood inside the anterior chamber can clog the routes that let aqueous humor fluid in that chamber drain out. The added blood and slowed drainage can increase your eye’s internal pressure (intraocular pressure), leading to ocular hypertension. That can quickly turn into glaucoma and put you at risk for permanent blindness.
• Rebleeding. This is when the original cause of your hyphema starts bleeding again. It’s most likely to happen within 72 hours of the initial bleeding. Rebleeding is usually more severe, and it greatly increases the chance of long-term vision and eye issues, so preventing it is a high priority.
• Corneal blood staining. Blood inside your anterior chamber can stain the back layer of your cornea. This is more likely to happen with higher-grade hyphemas, especially grades 3 and 4. The staining may cause a long-term reddish tint in your vision in your affected eye.

Experts estimate sickle cell disease (including sickle cell trait) affects up to 10% of people of African descent, and sickle cell disease can make hyphema worse. That’s because sickle cell disease causes red blood cells to take on a sickle-like shape, and those differently shaped cells are more prone to getting stuck and clogging your anterior chamber’s drainage routes.

How is hyphema diagnosed?

An eye care specialist or another medical professional, especially an emergency room provider, can diagnose hyphemas using a few simple parts of an eye exam.

The eye-specific tests your provider may use include:

• Visual acuity test.
• Slit lamp exam.
• Gonioscopy.
• Tonometry.
• Ultrasound.

Your provider or eye specialist may also recommend specific blood tests to check for or rule out certain blood disorders. Your specialist may recommend other tests, depending on the underlying cause or your symptoms, and they can tell you more about the specific tests and how they can help.

How is hyphema treated?

There are several potential treatments for hyphema. None of them will cure it, but they can prevent — or at least reduce your risk of developing — severe complications.

When hyphema isn’t severe and/or has a lower risk of complications, conservative treatments may be all you need. Some treatments are there to prevent more serious complications. Your provider may use combinations of the following treatments:

• Rest. Avoid strenuous activity that might raise the pressure inside your eye while it recovers. You should also avoid activities that are hard on your eyes like reading or watching TV.
• Eye protection. Wearing an eye patch or eye shield protects your eye from additional irritation. It also helps your eye relax while it heals.
• Head elevation. Keeping your head raised above your heart (especially while you sleep) helps the pooled blood drain out of your eye.
• Medications. The medications that are most likely to help include anti-inflammatory drugs and glaucoma medications to prevent you from developing glaucoma. Healthcare providers often recommend over-the-counter (OTC) painkillers like acetaminophen (Tylenol® or Panadol®) to treat eye pain from hyphema. They’ll probably recommend that you avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil® or Motrin®) or aspirin because they can increase the risk of rebleeding.
• Surgery. Only around 5% of people with hyphema need surgery to repair it. Surgery usually isn’t necessary unless bleeding or other symptoms could cause permanent eye damage.

How is hyphema treated?

If the hyphema is a lower grade and isn’t causing other symptoms or issues, you’ll only need at-home treatment. Conservative treatments usually include:

• Rest: Avoid intense activity that might raise the pressure inside your eye while it recovers.
• Wearing an eye patch: A patch will protect your eye from additional irritation and will help it relax while it heals.
• Elevating your head: Keeping your head raised above your heart will help the built-up blood drain away from your eye and back into your body.

Hyphema surgery

Only around 5% of people with hyphema need surgery to repair it. If you have severe bleeding and pressure inside your eye that doesn’t start to improve within 24 hours — or if your symptoms are severe enough to permanently damage your eye — you might need surgery.

Your surgeon will drain the blood from inside your eye to remove the pressure.

How to take care of myself?

Follow any directions from your provider or surgeon while you’re recovering from hyphema. If you have a patch to wear, make sure you wear it for as long and as often as you should. Hyphema usually resolves on its own in a few days.

Even if you only need conservative treatment, the first five days after you develop hyphema are the most important. You’ll be at a higher risk of re-aggravating your eye, which can cause the bleeding to start again. This can lead to serious complications, including permanent vision loss.

Can hyphema be prevented?

Yes, some hyphemas are extremely preventable. Experts estimate that 90% of hyphemas from sports-related injuries are preventable with proper eye protection like protective masks, glasses or goggles. Eye protection is also a crucial way to prevent hyphema from eye injuries related to activities like using power tools. Make sure you use the right kind of eye protection and don’t rely on regular glasses to do the same job.

Spontaneous hyphemas happen unpredictably and without an obvious injury or cause. Because of that, there’s no way to prevent them.

What’s the outlook for hyphema?

Hyphemas are medical emergencies because they can cause complications that lead to permanent eye damage and vision loss. But quick medical care can help you avoid those complications. And most people will recover from hyphema in about five to seven days with conservative treatments and the right care.

When should I see my healthcare provider or seek care?

After you receive initial treatment for hyphema, the following are signs and symptoms that mean you need to get medical attention immediately:

• If you notice more new blood accumulating in front of your iris.
• If you have sudden vision change or vision loss.
• If you notice a change in your pain level, or you have additional symptoms like nausea and vomiting (these can mean the pressure inside your eye is too high).

Your eye specialist or other provider can also tell you if there are any other signs and symptoms that you should watch for.

What questions should I ask my doctor?

Questions you may want to ask your provider include:

• What caused or contributed to my hyphema?
• How severe is my hyphema?
• Will I need any other tests?
• What treatment(s) will I need?
• How long will recovery take?
• What are the things I might notice that mean I need to call your office or go to the emergency room?

What’s the difference between hyphema and subconjunctival hemorrhage?

Hyphema is bleeding inside your eye that causes bleeding into the anterior chamber of your eye. With hyphema, it looks like the blood is where your eye color is. In contrast, a subconjunctival hemorrhage is a term for a broken blood vessel in the whites (sclera) of your eye. Hyphema causes pain, and subconjunctival hemorrhage doesn’t hurt. But both can happen at the same time, especially from an injury or trauma.

A note from Cleveland Clinic

Hyphema can be a frightening thing to see. While this condition is serious and needs immediate medical attention, getting care quickly improves your odds of avoiding complications and protecting your vision.

Most people only need medications, rest or other conservative measures while their eyes heal. Your eye care specialist can also help reassure you and guide you on what you can do to improve the odds of recovery in your specific situation.