UMEM Educational Pearls

Category: Misc

Title: The Pearls and Pitfalls of Hyphema

Keywords: Hyphema IOP Ophthalmology (PubMed Search)

Posted: 2/11/2009 by Ben Lawner, DO (Updated: 4/24/2024)
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Hyphema is an urgent ophthalmologic condition. Due to the high risk of rebleeding and increased intra-ocular pressure, strict follow up with an ophthalmologist is warranted. SELECTED low grade hyphemas in reliable patients may be managed on an outpatient basis. Some pointers that may be helpful for the EM inservice exam: 

  • Measurement of intra-ocular pressure (IOP)  is crucial to proper treatment and prognosis.
  • Many drugs are available to lower IOP, these are generally used in association with opthalmologic consultation
    ->acetazolamide (has potential to "sickle" RBC's)
    ->aminocaproic acid
    ->B blockers
  • Hyphema > 5 days are associated with high incidence of synechiae formation
  • Avoid NSAIDs/ ASA
  • Eye patching,  HOB (head of bed) elevation recommended
  • Corneal bloodstaining indicates a poor prognosis
  • Incidence of rebleeding estimated at 30-40%
  • Graded from 0-IV. Grade IV hyphemas cover the entire anteror chamber; often called, "8 ball" or "blackball" hyphema. Grade 0=only visible on slit lamp.
  • Trauma is most common etiology
  • Low IOP and trauma? ---> Rule out globe rupture! 

General indications for "very urgent" ophthalmologic consultation:

  • Severely impaired visual acuity=greater rebleeding risk
  • Patient with known SCD or sickle cell trait
  • Visible blood staining of cornea
  • High grade, covering > 1/3 of anterior chamber
  • Delayed presentation (risk of synechiae / vision loss due to IOP) 



  • Brunette D. "Ophthalmology" Marx: Rosen's Emergency Medicine. Concepts and Clinical Practice, 6th Edition. 2006:Mosby.
  • Naradzay J. "Approach to ophthalmologic emergencies" Med Clin North Am. 2006;90(2):305-28.
  • Kahn J, Robinett, DA. "Physical examination of the eye" Emerg Med Clin N Am. 2008;26:1-16
  • Bord SP, Linden J. "Trauma to the globe and orbit" Emerg Med Clin N Am 2008;26:97-123.