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Liebman DL, Aboobakar IF. Traumatic Hyphema: Diagnostic and Management Considerations. Int Ophthalmol Clin 2024; 64:49-61. [PMID: 38525981 DOI: 10.1097/iio.0000000000000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
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Woreta FA, Lindsley KB, Gharaibeh A, Ng SM, Scherer RW, Goldberg MF. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev 2023; 3:CD005431. [PMID: 36912744 PMCID: PMC10010597 DOI: 10.1002/14651858.cd005431.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Traumatic hyphema is the entry of blood into the anterior chamber, the space between the cornea and iris, following significant injury to the eye. Hyphema may be associated with significant complications that uncommonly cause permanent vision loss. Complications include elevated intraocular pressure, corneal blood staining, anterior and posterior synechiae, and optic nerve atrophy. People with sickle cell trait or disease may be particularly susceptible to increases in intraocular pressure and optic atrophy. Rebleeding is associated with an increase in the rate and severity of complications. OBJECTIVES To assess the effectiveness of various medical interventions in the management of traumatic hyphema. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 3); MEDLINE Ovid; Embase.com; PubMed (1948 to March 2022); the ISRCTN registry; ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The last date of the search was 22 March 2022. SELECTION CRITERIA Two review authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. We included randomized and quasi-randomized trials that compared various medical (non-surgical) interventions versus other medical interventions or control groups for the treatment of traumatic hyphema following closed-globe trauma. We applied no restrictions on age, gender, severity of the closed-globe trauma, or level of visual acuity at time of enrollment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and assessed the certainty of evidence using GRADE. MAIN RESULTS We included 23 randomized and seven quasi-randomized studies with a total of 2969 participants. Interventions included antifibrinolytic agents (systemic and topical aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest. We found no evidence of an effect on visual acuity for any intervention, whether measured within two weeks (short term) or for longer periods. In a meta-analysis of two trials, we found no evidence of an effect of aminocaproic acid on long-term visual acuity (RR 1.03, 95% confidence interval (CI) 0.82 to 1.29) or final visual acuity measured up to three years after the hyphema (RR 1.05, 95% CI 0.93 to 1.18). Oral tranexamic acid appeared to provide little to no benefit on visual acuity in four trials (RR 1.12, 95% CI 1.00 to 1.25). The remaining trials evaluated the effects of various interventions on short-term visual acuity; none of these interventions was measured in more than one trial. No intervention showed a statistically significant effect (RRs ranged from 0.75 to 1.10). Similarly, visual acuity measured for longer periods in four trials evaluating different interventions was also not statistically significant (RRs ranged from 0.82 to 1.02). The evidence supporting these findings was of low or very low certainty. Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (RR 0.28, 95% CI 0.13 to 0.60), as assessed in six trials with 330 participants. A sensitivity analysis omitting two studies not using an intention-to-treat analysis reduced the strength of the evidence (RR 0.43, 95% CI 0.17 to 1.08). We obtained similar results for topical aminocaproic acid (RR 0.48, 95% CI 0.20 to 1.10) in two trials with 131 participants. We assessed the certainty of the evidence as low. Systemic tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (RR 0.33, 95% CI 0.21 to 0.53) in seven trials with 754 participants, as did aminomethylbenzoic acid (RR 0.10, 95% CI 0.02 to 0.41), as reported in one study. Evidence to support an associated reduction in risk of complications from secondary hemorrhage (i.e. corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no evidence of an effect on the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The number of days for the primary hyphema to resolve appeared to be longer with the use of systemic aminocaproic acid compared with no use, but this outcome was not altered by any other intervention. The available evidence on usage of systemic or topical corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials. We found no evidence of an effect between a single versus binocular patch on the risk of secondary hemorrhage or time to rebleed. We also found no evidence of an effect on the risk of secondary hemorrhage between ambulation and complete bed rest. AUTHORS' CONCLUSIONS We found no evidence of an effect on visual acuity of any of the interventions evaluated in this review. Although the evidence was limited, people with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhage. However, hyphema took longer to clear in people treated with systemic aminocaproic acid. There is no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphema, other than possibly to reduce the rate of secondary hemorrhage. The potentially long-term deleterious effects of secondary hemorrhage are unknown. Similarly, there is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions (such as patching, bed rest, or head elevation) in the management of traumatic hyphema. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.
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Affiliation(s)
- Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristina B Lindsley
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Almutez Gharaibeh
- Department of Special Surgery-Ophthalmology, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Sueko M Ng
- Department of Ophthalmology, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Roberta W Scherer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Morton F Goldberg
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bowe T, Serina A, Armstrong M, Welcher JE, Adebona O, Gore C, Staffa SJ, Zurakowski D, Shah AS. Timing of Ocular Hypertension After Pediatric Closed-Globe Traumatic Hyphema: Implications for Surveillance. Am J Ophthalmol 2022; 233:135-143. [PMID: 33991515 DOI: 10.1016/j.ajo.2021.04.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the timing of ocular hypertension (OHT) after pediatric closed-globe injury (CGI) and traumatic hyphema. We hypothesize that OHT will occur at different times based on injury characteristics. DESIGN Retrospective, cohort study. METHODS Setting: Single-center, tertiary-care, pediatric hospital. PARTICIPANTS Subjects included patients ≤18 years of age at the time of injury who suffered CGI and traumatic hyphema between 2002 and 2019. Observation Procedure(s): Intraocular pressure and injury demographics were abstracted for every visit after injury. OHT was defined as >21 mm Hg at presentation or after a reading of ≤21 mm Hg at a prior visit. MAIN OUTCOME MEASURES The primary outcome measure was the timing of OHT categorized into 4 periods: presentation, acute (days 1-7), subacute (days 8-28), or late (day >28). Secondary outcome measures were identification of risks factors for OHT by multivariable logistic regression. RESULTS OHT occurred in 119 of the 305 (39%) subject eyes. OHT occurred in 35 patients at presentation, 69 times acutely, 35 times subacutely, and 36 times late. Pupil damage predicted acute-period OHT (P = .004). OHT at presentation predicted subacute period OHT (P = .004). Iridodialysis and cataract predicted late-period OHT (P = .007 and P < .001, respectively). CONCLUSIONS OHT after CGI and traumatic hyphema in pediatric patients is common. Injury demographics predict this complication. Integration of these risk factors with current literature allows proposal of a risk-stratification tool to guide efficient surveillance for OHT.
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Affiliation(s)
- Theodore Bowe
- From Harvard Medical School (T.B., D.Z., A.S.S.); Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.); Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA (T.B., A.S.S.)
| | - Anthony Serina
- Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.)
| | - Mikhayla Armstrong
- Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.)
| | - Jennifer E Welcher
- Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.)
| | - Olumuyiwa Adebona
- Department of Family Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada (O.A.)
| | - Charlotte Gore
- Department of Ophthalmology, University of California Irvine, Irvine, CA, USA (C.G.)
| | - Steven J Staffa
- Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.)
| | - David Zurakowski
- From Harvard Medical School (T.B., D.Z., A.S.S.); Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.)
| | - Ankoor S Shah
- From Harvard Medical School (T.B., D.Z., A.S.S.); Department of Ophthalmology, Boston Children's Hospital (T.B., A.S., M.A., J.W., D.Z., A.S.S.); Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital (S.J.S, D.Z.); Department of Ophthalmology, Massachusetts Eye and Ear, Boston, Massachusetts, USA (T.B., A.S.S.).
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Iftikhar M, Mir T, Seidel N, Rice K, Trang M, Bhowmik R, Chun J, Goldberg MF, Woreta FA. Epidemiology and outcomes of hyphema: a single tertiary centre experience of 180 cases. Acta Ophthalmol 2021; 99:e394-e401. [PMID: 33124159 DOI: 10.1111/aos.14603] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/21/2020] [Accepted: 08/01/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE To characterize the epidemiology and outcomes of hyphema. METHODS Retrospective case series. Medical records from patients with traumatic and spontaneous hyphema seen at the Wilmer Eye Institute, Johns Hopkins, from 2011 through 2017 were evaluated. Aetiology, demographics, clinical characteristics, complications, management and outcomes were ascertained. Multivariable logistic regression was used to identify factors associated with elevated intraocular pressure (IOP), rebleeding and poor outcome (final visual acuity ≤ 20/40) in traumatic hyphema. A safe frequency of follow-up was retrospectively determined. RESULTS Traumatic hyphema (n = 152) was more common in males (78%) and adults (55%), with sports/recreational activities being the most frequent cause (40%). Elevated IOP was the most common complication (39%). Rebleeding occurred in seven patients (5%) and was more likely with a higher IOP on presentation (OR:1.1; p = 0.004). Thirty-seven patients (24%) had a poor outcome, mostly due to traumatic sequelae such as cataract (32%) or posterior segment involvement (30%). A poor outcome was more likely with worse presenting visual acuity (OR: 9.1; p = 0.001), rebleeding (OR: 37.5; p = 0.035) and age > 60 years (OR: 16.0; p = 0.041). Spontaneous hyphema (n = 28) did not have a gender predominance and was more common in adults > 60 years (71%). The most common cause was iris neovascularization (61%). Complications and visual outcomes were worse compared with traumatic hyphema. CONCLUSIONS Traumatic hyphema continues to be common in young males engaging in sports, necessitating increased awareness for preventive eyewear. Older age and rebleeding can lead to poor outcomes. Elevated IOP at presentation predisposes to rebleeding and warrants frequent follow-up. Otherwise, routine follow-up at days 1, 3, 5, 7 and 14 is sufficient for uncomplicated cases.
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Affiliation(s)
- Mustafa Iftikhar
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Tahreem Mir
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Natalie Seidel
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Katya Rice
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Michelle Trang
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Ryan Bhowmik
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Justin Chun
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Morton F. Goldberg
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
| | - Fasika A. Woreta
- Wilmer Eye Institute Johns Hopkins University School of Medicine Baltimore MD USA
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Mir T, Iftikhar M, Seidel N, Trang M, Goldberg MF, Woreta FA. Clinical Characteristics and Outcomes of Hyphema in Patients with Sickle Cell Trait: 10-Year Experience at the Wilmer Eye Institute. Clin Ophthalmol 2020; 14:4165-4172. [PMID: 33293789 PMCID: PMC7719005 DOI: 10.2147/opth.s281875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose To report the clinical characteristics, complications, and outcomes of hyphema in patients with sickle cell trait (SCT). Design Retrospective case series. Methods Medical records of SCT patients (confirmed by hemoglobin electrophoresis) presenting with hyphema at the Wilmer Eye Institute over 10 years (January 2008 through December 2017) were reviewed in detail. Data were collected regarding etiology, demographics, clinical course and management. Main outcome measures included intraocular pressure (IOP) and visual acuity (VA). Results A total of 14 black patients (males: 57%; median age: 20 years) were included in the study with a median follow-up of 4 months (range: 1 week to 6 years). Ten patients had traumatic hyphema with a mean presenting VA of approximately 1.10 logMAR (Snellen equivalent=20/250) and a mean presenting IOP of 40 mmHg. Nine of them required medical intervention to lower IOP, and six of them ultimately required surgical intervention, primarily in the form of anterior chamber paracentesis and/or washout. The mean time to achieve IOP control was 3 days, and the mean final VA was approximately 0.10 logMAR (Snellen Equivalent=20/25). Four patients had non-traumatic hyphema with a mean presenting VA of approximately 1.8 logMAR (Snellen equivalent=20/1260) and a mean presenting IOP of 31 mmHg. Three of them required medical intervention to lower IOP, and two of them ultimately required surgical intervention. Overall, seven patients underwent anterior chamber washout, six needed an anterior chamber paracentesis to lower the IOP, two required tube shunt placement procedures and one patient underwent a trabeculectomy. The mean time to achieve IOP control was 5 days, and the mean final VA was approximately 0.80 logMAR (Snellen equivalent=20/125). Conclusion Patients with SCT are likely to develop elevated IOP in the setting of hyphema, with a majority requiring one or more surgical interventions to achieve IOP control.
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Affiliation(s)
- Tahreem Mir
- Department of Ophthalmology & Visual Science, Yale School of Medicine, New Haven, CT, USA
| | - Mustafa Iftikhar
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Natalie Seidel
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle Trang
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Morton F Goldberg
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fasika A Woreta
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zafar S, Canner JK, Mir T, Srikumaran D, Channa R, Goldberg MF, Thorne J, Woreta FA. Epidemiology of Hyphema-Related Emergency Department Visits in The United States Between 2006 and 2015. Ophthalmic Epidemiol 2019; 26:208-215. [PMID: 30794001 DOI: 10.1080/09286586.2019.1579917] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sidra Zafar
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, USA
| | - Joseph K. Canner
- , Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins Hospital, Baltimore, USA
| | - Tahreem Mir
- Department of Ophthalmology & Visual Science, Yale School of Medicine, New Haven, USA
- Department of Ophthalmology, West Virginia University School of Medicine, Morgantown, USA
| | | | - Roomasa Channa
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, USA
- Department of Ophthalmology, Baylor College of Medicine, Houston, USA
| | | | - Jennifer Thorne
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, USA
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Abstract
BACKGROUND Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of vision. Associated trauma (e.g. corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may seriously affect vision. Such complications can lead to permanent impairment of vision. People with sickle cell trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates and severity of complications increase. OBJECTIVES To assess the effectiveness of various medical interventions in the management of traumatic hyphema. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); MEDLINE Ovid; Embase.com; PubMed (1948 to June 2018); the ISRCTN registry; ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). The date of the search was 28 June 2018. SELECTION CRITERIA Two review authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included randomized and quasi-randomized trials that compared various medical (non-surgical) interventions versus other medical intervention or control groups for the treatment of traumatic hyphema following closed-globe trauma. We applied no restrictions regarding age, gender, severity of the closed-globe trauma, or level of visual acuity at the time of enrollment. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data for the primary outcomes, visual acuity and time to resolution of primary hemorrhage, and secondary outcomes including: secondary hemorrhage and time to rebleed; risk of corneal blood staining, glaucoma or elevated intraocular pressure, optic atrophy, or peripheral anterior synechiae; adverse events; and duration of hospitalization. We entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as risk ratios (RR) and continuous outcomes as mean differences (MD). MAIN RESULTS We included 20 randomized and seven quasi-randomized studies with a total of 2643 participants. Interventions included antifibrinolytic agents (systemic and topical aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest.We found no evidence of an effect on visual acuity for any intervention, whether measured within two weeks (short term) or for longer periods. In a meta-analysis of two trials, we found no evidence of an effect of aminocaproic acid on long-term visual acuity (RR 1.03, 95% confidence interval (CI) 0.82 to 1.29) or final visual acuity measured up to three years after the hyphema (RR 1.05, 95% CI 0.93 to 1.18). Eight trials evaluated the effects of various interventions on short-term visual acuity; none of these interventions was measured in more than one trial. No intervention showed a statistically significant effect (RRs ranged from 0.75 to 1.10). Similarly, visual acuity measured for longer periods in four trials evaluating different interventions was also not statistically significant (RRs ranged from 0.82 to 1.02). The evidence supporting these findings was of low or very low certainty.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (RR 0.28, 95% CI 0.13 to 0.60) as assessed in six trials with 330 participants. A sensitivity analysis omitting two studies not using an intention-to-treat analysis reduced the strength of the evidence (RR 0.43, 95% CI 0.17 to 1.08). We obtained similar results for topical aminocaproic acid (RR 0.48, 95% CI 0.20 to 1.10) in two studies with 121 participants. We assessed the certainty of these findings as low and very low, respectively. Systemic tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (RR 0.31, 95% CI 0.17 to 0.55) in five trials with 578 participants, as did aminomethylbenzoic acid as reported in one study (RR 0.10, 95% CI 0.02 to 0.41). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e. corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no evidence of an effect in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The number of days for the primary hyphema to resolve appeared to be longer with the use of systemic aminocaproic acid compared with no use, but this outcome was not altered by any other intervention.The available evidence on usage of systemic or topical corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no evidence of an effect between a single versus binocular patch or ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed. AUTHORS' CONCLUSIONS We found no evidence of an effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears that people with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema took longer clear in people treated with systemic aminocaproic acid.There is no good evidence to support the use of antifibrinolytic agents in the management of traumatic hyphema other than possibly to reduce the rate of secondary hemorrhage. Similarly, there is no evidence to support the use of corticosteroids, cycloplegics, or non-drug interventions (such as binocular patching, bed rest, or head elevation) in the management of traumatic hyphema. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.
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Affiliation(s)
- Almutez Gharaibeh
- Faculty of Medicine, The University of JordanDepartment of Special Surgery‐OphthalmologyP.O. Box 13046AmmanJordan
| | - Howard I Savage
- Kaiser Permanente Largo Medical Center1221 Mercantile LaneLargoMarylandUSA20774
| | - Roberta W Scherer
- Johns Hopkins Bloomberg School of Public HealthDepartment of EpidemiologyRoom W6138615 N. Wolfe St.BaltimoreMarylandUSA21205
| | - Morton F Goldberg
- Johns Hopkins University School of MedicineWilmer Eye Institute600 N. Wolfe StreetMaumenee, 7th floorBaltimoreMarylandUSA21287
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of EpidemiologyRoom W6138615 N. Wolfe St.BaltimoreMarylandUSA21205
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Abstract
PURPOSE To determine the rate of visual recovery following hyphema caused by traumatic blunt force injury in children. METHODS The medical records of patients evaluated between July 2008 and July 2014 were reviewed retrospectively. Primary outcome measures included presenting and follow-up visual acuities. RESULTS At total of 56 eyes of 55 children (<18 years of age) were diagnosed with hyphema following blunt force nonpenetrating injury. The average patient age was 10.3 ± 3.2 years. The majority of subjects were male (78%). Presenting visual acuities ranged from logMAR 0.0 (Snellen equivalent, 20/20) to light perception. Rebleeding occurred in 4 subjects (7.1%). Visual acuity demonstrated improvement over the first 28 days following injury, with 59% achieving visual acuity of logMAR 0.0 (Snellen equivalent, 20/20) and 82% recovering vision to logMAR 0.2 (Snellen equivalent 20/30) by day 28. All but 1 patient (43 of 44 eyes, 98%) had a best-corrected visual acuity of better than or equal to logMAR 0.2 at their last recorded follow-up. CONCLUSIONS There is good potential for visual recovery following uncomplicated traumatic hyphema in children. In our patient cohort, the majority of patients had significant improvement in visual acuity within the first 28 days; in some children visual acuity continued to improve beyond the first month.
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Affiliation(s)
- Erin A Boese
- Oregon Health & Science University, Casey Eye Institute, Portland; University of Michigan, Kellogg Eye Center, Ann Arbor.
| | - Daniel J Karr
- Oregon Health & Science University, Casey Eye Institute, Portland
| | - Michael F Chiang
- Oregon Health & Science University, Casey Eye Institute, Portland; Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland
| | - Laura J Kopplin
- Oregon Health & Science University, Casey Eye Institute, Portland; Medical College of Wisconsin, Department of Ophthalmology & Visual Sciences, Milwaukee
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Bansal S, Gunasekeran DV, Ang B, Lee J, Khandelwal R, Sullivan P, Agrawal R. Controversies in the pathophysiology and management of hyphema. Surv Ophthalmol 2015; 61:297-308. [PMID: 26632664 DOI: 10.1016/j.survophthal.2015.11.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 11/12/2015] [Accepted: 11/23/2015] [Indexed: 11/27/2022]
Abstract
Traumatic hyphemas present dilemmas to physicians. There are numerous controversies pertaining to the optimal approach to traumatic hyphema and no standardized guidelines for its management. We address some of these controversies and present a pragmatic approach. We discuss various medical agents and surgical techniques available for treatment, along with the indications for their use. We address the complications associated with hyphema and how to diagnose and manage them and consider the management of hyphema in special situations such as in children and sickle-cell anemia and in rare clinical syndromes such as recurrent hyphema after placement of anterior chamber intraocular lenses.
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Affiliation(s)
- Svati Bansal
- Department of Neuroophthamlology, Singapore National Eye Centre, Singapore, Singapore
| | - Dinesh Visva Gunasekeran
- Department of Ophthalmology, National Healthcare Group Eye Insitute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bryan Ang
- Department of Ophthalmology, National Healthcare Group Eye Insitute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jiaying Lee
- Department of Ophthalmology, National Healthcare Group Eye Insitute, Tan Tock Seng Hospital, Singapore, Singapore
| | - Rekha Khandelwal
- Department of Ophthalmology, NKP Salve Institute of Medical Sciences, Nagpur, India
| | - Paul Sullivan
- Medical Retina Department, Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Rupesh Agrawal
- Department of Ophthalmology, National Healthcare Group Eye Insitute, Tan Tock Seng Hospital, Singapore, Singapore; Medical Retina Department, Moorfields Eye Hospital, NHS Foundation Trust, London, UK; School of Material Science and Engineering, Nanyang Technological University, Singapore, Singapore.
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Abstract
BACKGROUND Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of vision. Associated trauma (e.g. corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may seriously affect vision. Such complications may lead to permanent impairment of vision. Patients with sickle cell trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates and severity of complications increase. OBJECTIVES To assess the effectiveness of various medical interventions in the management of traumatic hyphema. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2013), EMBASE (January 1980 to August 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 30 August 2013. SELECTION CRITERIA Two authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included randomized and quasi-randomized trials that compared various medical interventions versus other medical interventions or control groups for the treatment of traumatic hyphema following closed globe trauma. We applied no restrictions regarding age, gender, severity of the closed globe trauma, or level of visual acuity at the time of enrolment. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data for the primary and secondary outcomes. We entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as odds ratios and continuous outcomes as mean differences. MAIN RESULTS We included 20 randomized and seven quasi-randomized studies with 2643 participants in this review. Interventions included antifibrinolytic agents (oral and systemic aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, traditional Chinese medicine, monocular versus bilateral patching, elevation of the head, and bed rest. No intervention had a significant effect on visual acuity whether measured at two weeks or less after the trauma or at longer time periods. The number of days for the primary hyphema to resolve appeared to be longer with the use of aminocaproic acid compared with no use, but was not altered by any other intervention.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (odds ratio (OR) 0.25, 95% confidence interval (CI) 0.11 to 0.57), but a sensitivity analysis omitting studies not using an intention-to-treat (ITT) analysis reduced the strength of the evidence (OR 0.41, 95% CI 0.16 to 1.09). We obtained similar results for topical aminocaproic acid (OR 0.42, 95% CI 0.16 to 1.10). We found tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (OR 0.25, 95% CI 0.13 to 0.49), as did aminomethylbenzoic acid as reported in one study (OR 0.07, 95% CI 0.01 to 0.32). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e. corneal bloodstaining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compared with placebo. We found no difference in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The available evidence on usage of corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no difference in effect between a single versus binocular patch or ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed. AUTHORS' CONCLUSIONS Traumatic hyphema in the absence of other intraocular injuries uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to permanent impairment of vision, especially in patients with sickle cell trait/disease. We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients treated with aminocaproic acid take longer to clear.Other than the possible benefits of antifibrinolytic usage to reduce the rate of secondary hemorrhage, the decision to use corticosteroids, cycloplegics, or nondrug interventions (such as binocular patching, bed rest, or head elevation) should remain individualized because no solid scientific evidence supports a benefit. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.
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Affiliation(s)
- Almutez Gharaibeh
- Department of Special Surgery-Ophthalmology, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Howard I Savage
- Kaiser Permanente Largo Medical Center, Largo, Maryland, USA
| | - Roberta W Scherer
- Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Morton F Goldberg
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kristina Lindsley
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Abstract
A case report of a traumatic hyphema in a patient with sickle cell trait is presented. A review of the published literature in PubMed was performed and medical management strategies and surgical treatment indications for traumatic hyphema are discussed. We support the case for temporary trabeculectomy in patients with traumatic hyphema and sickle cell disease.
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Affiliation(s)
- Kevin Kaplowitz
- Department of Ophthalmology, State University of New York at Stony Brook , Stony Brook, New York , USA
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Al Ali AK, Al Mass D, Bener A. Poor final visual outcome after traumatic hyphema: A retrospective study of associated factors. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2012. [DOI: 10.5339/jemtac.2012.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
BACKGROUND Traumatic hyphema is the entry of blood into the anterior chamber (the space between the cornea and iris) subsequent to a blow or a projectile striking the eye. Hyphema uncommonly causes permanent loss of vision. Associated trauma (e.g., corneal staining, traumatic cataract, angle recession glaucoma, optic atrophy, etc.) may seriously affect vision. Such complications may lead to permanent impairment of vision. Patients with sickle cell trait/disease may be particularly susceptible to increases of elevated intraocular pressure. If rebleeding occurs, the rates and severity of complications increase. OBJECTIVES The objective of this review was to assess the effectiveness of various medical interventions in the management of traumatic hyphema. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 6), MEDLINE (January 1950 to June 2010), EMBASE (January 1980 to June 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (http://clinicaltrials.gov). We searched the reference lists of identified trial reports to find additional trials. We also searched the ISI Web of Science Social Sciences Citation Index (SSCI) to find studies that cited the identified trials. There were no language or date restrictions in the search for trials. The electronic databases were last searched on 25 June 2010. SELECTION CRITERIA Two authors independently assessed the titles and abstracts of all reports identified by the electronic and manual searches. In this review, we included randomized and quasi-randomized trials that compared various medical interventions to other medical interventions or control groups for the treatment of traumatic hyphema following closed globe trauma. There were no restrictions regarding age, gender, severity of the closed globe trauma or level of visual acuity at the time of enrollment. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data for the primary and secondary outcomes. We entered and analyzed data using Review Manager (RevMan) 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as odds ratios and continuous outcomes as mean differences. MAIN RESULTS Nineteen randomized and seven quasi-randomized studies with 2,560 participants were included in this review. Interventions included antifibrinolytic agents (oral and systemic aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, monocular versus bilateral patching, elevation of the head, and bed rest. No intervention had a significant effect on visual acuity whether measured at two weeks or less after the trauma or at longer time periods. The number of days for the primary hyphema to resolve appeared to be longer with the use of aminocaproic acid compared to no use, but was not altered by any other intervention.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (odds ratio (OR) 0.25, 95% confidence interval (CI) 0.11 to 0.5), but a sensitivity analysis omitting studies not using an intention-to-treat (ITT) analysis reduced the strength of the evidence (OR 0.41, 95% CI 0.16 to 1.09). We obtained similar results for topical aminocaproic acid (OR 0.42, 95% CI 0.16 to 1.10). We found tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (OR 0.25, 95% CI 0.13 to 0.49), as did aminomethylbenzoic acid as reported in a single study (OR 0.07, 95% CI 0.01 to 0.32). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e., corneal blood staining, peripheral anterior synechiae, elevated intraocular pressure, and development of optic atrophy) by antifibrinolytics was limited by the small number of these events. Use of aminocaproic acid was associated with increased nausea, vomiting, and other adverse events compares with placebo. We found no difference in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The available evidence on usage of corticosteroids, cycloplegics or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no difference in effect between a single versus binocular patch nor ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed. AUTHORS' CONCLUSIONS Traumatic hyphema in the absence of other intraocular injuries, uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to permanent impairment of vision, especially in patients with sickle cell trait/disease. We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review. Although evidence is limited, it appears that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients on aminocaproic acid take longer to clear.Other than the possible benefits of antifibrinolytic usage to reduce the rate of secondary hemorrhage, the decision to use corticosteroids, cycloplegics, or non-drug interventions (such as binocular patching, bed rest, or head elevation) should remain individualized because no solid scientific evidence supports a benefit. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.
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Affiliation(s)
- Almutez Gharaibeh
- Department of Special Surgery-Ophthalmology, Faculty of Medicine, The University of Jordan, Amman, Jordan
| | - Howard I Savage
- Kaiser Permanente Largo Medical Center, Maryland, Largo, USA
| | - Roberta W Scherer
- Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Maryland, Baltimore, USA
| | - Morton F Goldberg
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Maryland, Baltimore, USA
| | - Kristina Lindsley
- Center for Clinical Trials, Johns Hopkins University Bloomberg School of Public Health, Maryland, Baltimore, USA
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Ashaye AO. Traumatic hyphaema: a report of 472 consecutive cases. BMC Ophthalmol 2008; 8:24. [PMID: 19036128 PMCID: PMC2610027 DOI: 10.1186/1471-2415-8-24] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 11/26/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Strategies for prevention of eye injuries require knowledge of the cause of the injuries. This study was done to determine the patient characteristics, the cause of injury, and where cases of traumatic hyphaema that necessitated admission to a tertiary hospital occurred. This may enable an appropriate intervention in the prevention of such injuries. METHODS Retrospective case analysis of 472 patients with traumatic hyphaema admitted to the University College Hospital, Ibadan between January 1997 and December 2006. RESULTS The home was the single most frequent place of injury for all cases and for 75% of cases in children aged 0-10 years. Injuries that occurred at school comprised about one-fifth of cases. Sport-related injuries were uncommon. The most common activities preceding injuries were play, corporal punishment and assault. Stones, sticks and whiplash were the agents that caused traumatic hyphaema. Occupational-related hyphaema that caused injuries was mostly in farmers and artisans, few of whom used protective goggles. The majority of patients were males. Children and young adults aged <or= 20 years comprised 63.6% of patients. A total of 336 (76%) eyes had at least one surgical intervention. While 298 (73.2%) patients had visual acuity (VA) less than 6/60 at presentation, 143 (37.0%) of eyes had visual acuity (VA) < 6/60 3 months after injury. CONCLUSION The injuries leading to traumatic hyphaema occur mostly at home and school, and frequently affect children and young adolescents. Over one-third resulted in blindness in the affected eye. The focus should be on prevention of stick-related eye injuries at these locations and improving access to eye health services for patients who sustained eye injuries.
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Affiliation(s)
- Adeyinka O Ashaye
- Department of Ophthalmology, University College Hospital, Ibadan, Nigeria.
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Viestenz A, Küchle M. [Blunt ocular trauma. Part I: blunt anterior segment trauma]. Ophthalmologe 2005; 101:1239-57; quiz 1257-8. [PMID: 15592849 DOI: 10.1007/s00347-004-1118-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Blunt ocular traumas include contusions and ruptures of the globe--open and closed globe injuries. Characteristic damage results in anterior and posterior segment trauma. Typical patterns of injuries are combinations of (1) hyphema grade II-IV, iris-lens injury, vitreal bleeding--choroidal rupture and increased risk of rebleeding, (2) angle recession >180 degrees--secondary open-angle glaucoma, and (3) vitreal prolapse and lens dislocation-retinal detachment. Patients with blunt eye trauma should be under steady observation by an ophthalmologist to handle late complications.
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Affiliation(s)
- A Viestenz
- Augenklinik mit Poliklinik der Universität Erlangen-Nürnberg, Erlangen.
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17
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Pieramici DJ, Goldberg MF, Melia M, Fekrat S, Bradford CA, Faulkner A, Juzych M, Parker JS, McLeod SD, Rosen R, Santander SH. A phase III, multicenter, randomized, placebo-controlled clinical trial of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. Ophthalmology 2003; 110:2106-12. [PMID: 14597516 DOI: 10.1016/s0161-6420(03)00866-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To determine the safety and efficacy of topical aminocaproic acid (Caprogel) in the management of traumatic hyphema. DESIGN Multicenter, randomized, double-masked, placebo-controlled clinical trial. PARTICIPANTS A total of 51 patients participated in this trial (power = 36%, 2-tailed test). INTERVENTION Patients presenting with traumatic hyphema were randomly assigned to 5-day treatment with topical aminocaproic acid or a placebo gel. Patients were monitored daily with ocular examination and vital sign testing for the 5 days of treatment and at 24 and 48 hours after treatment. General physical examination and laboratory testing were performed at baseline and day 5. MAIN OUTCOME MEASURES The main efficacy variable was the rate of rebleeding. Secondary efficacy variables included time to hyphema clearance, intraocular pressure, time to secondary hemorrhage, and visual acuity. Safety variables included adverse events, vital signs, and laboratory measurements. RESULTS Rebleeding occurred in 30% of the placebo group (8 of 27; 95% confidence interval [CI] = 14-50%), versus 8% of the treatment group (2 of 24; 95% CI = 1-27%), for an estimated continuity-corrected difference in percentage of patients with bleeding of 17% (95% CI = -3-38%). Secondary efficacy variables were similar in the groups, except that there was a trend towards more visual improvement in the topical aminocaproic acid group (54%) than in the placebo group (30%) at the last measurement (P = 0.08). Adverse events were similar. CONCLUSIONS This study provides evidence that topical aminocaproic acid is safe and demonstrates trends towards reducing the rebleeding rate in the management of traumatic hyphema. However, because the study was terminated before complete enrollment, more definitive recommendations will require a larger trial.
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Karkhaneh R, Naeeni M, Chams H, Abdollahi M, Mansouri MR. Topical aminocaproic acid to prevent rebleeding in cases of traumatic hyphema. Eur J Ophthalmol 2003; 13:57-61. [PMID: 12635675 DOI: 10.1177/112067210301300108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To determine the effect of topical aminocaproic acid on the incidence of rebleeding after traumatic hyphema. PATIENTS AND METHODS This randomized double blind clinical trial investigated 132 consecutive cases of traumatic hyphema referred to the emergency room of Farabi Eye Hospital in 1998-1999. The patients were randomly divided into three groups: Group 1 received cycloplegic drops only. Group 2 received cycloplegic drops and 2% carboxy polymethylene (CPM) gel as placebo. Group 3 was treated with cycloplegic drops and 25% aminocaproic acid (ACA) in CPM gel (supplied by Messrs. Sina Darou). All patients were treated for five days on an outpatient basis, with a two-week follow-up. The incidence of rebleeding, time needed for clot absorption, and complications of hyphema were recorded and analyzed using the chi-square and Student's t-tests and logistic regression modeling. RESULTS Rebleeding occurred in 8 eyes of 52 patients in group 1 (15.4%), 7 eyes of the 39 patients in group 2 (17.9%) and 5 eyes of the 41 patients in group 3 (12.2%). This difference was not significant. The time needed for clot absorption in groups 1, 2 and 3 was respectively 9.5 +/- 3.9, 9.3 +/- 4.2 and 11.15 +/- 4.7 days, the difference between group 3 and the other two groups being statistically significant (p<0.04). CONCLUSIONS Topical 25% ACA is not effective in reducing the incidence of rebleeding and lengthens the time needed for clot absorption.
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Affiliation(s)
- R Karkhaneh
- Department of Ophthalmology, Tehran University of Medical Sciences, Farabi Eye Hospital, Tehran, Iran
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19
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Affiliation(s)
- Prithvi S Sankar
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, 02114, USA
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20
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Crouch ER, Crouch ER. Discussion by Earl R. Crouch, Jr., MD, Eric R. Crouch, MD. Ophthalmology 2002. [DOI: 10.1016/s0161-6420(02)01092-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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21
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Abstract
Hyphema (blood in the anterior chamber) can occur after blunt or lacerating trauma, after intraocular surgery, spontaneously (e.g., in conditions such as rubeosis iridis, juvenile xanthogranuloma, iris melanoma, myotonic dystrophy, keratouveitis (e.g., herpes zoster), leukemia, hemophilia, von Willebrand disease, and in association with the use of substances that alter platelet or thrombin function (e.g., ethanol, aspirin, warfarin). The purpose of this review is to consider the management of hyphemas that occur after closed globe trauma. Complications of traumatic hyphema include increased intraocular pressure, peripheral anterior synechiae, optic atrophy, corneal bloodstaining, secondary hemorrhage, and accommodative impairment. The reported incidence of secondary anterior chamber hemorrhage, that is, rebleeding, in the setting of traumatic hyphema ranges from 0% to 38%. The risk of secondary hemorrhage may be higher in African-Americans than in whites. Secondary hemorrhage is generally thought to convey a worse visual prognosis, although the outcome may depend more directly on the size of the hyphema and the severity of associated ocular injuries. Some issues involved in managing a patient with hyphema are: use of various medications (e.g., cycloplegics, systemic or topical steroids, antifibrinolytic agents, analgesics, and antiglaucoma medications); the patient's activity level; use of a patch and shield; outpatient vs. inpatient management; and medical vs. surgical management. Special considerations obtain in managing children, patients with hemoglobin S, and patients with hemophilia. It is important to identify and treat associated ocular injuries, which often accompany traumatic hyphema. We consider each of these management issues and refer to the pertinent literature in formulating the following recommendations. We advise routine use of topical cycloplegics and corticosteroids, systemic antifibrinolytic agents or corticosteroids, and a rigid shield. We recommend activity restriction (quiet ambulation) and interdiction of non-steroidal anti-inflammatory agents. If there is no concern regarding compliance (with medication use or activity restrictions), follow-up, or increased risk for complications (e.g., history of sickle cell disease, hemophilia), outpatient management can be offered. Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.
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Affiliation(s)
- William Walton
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, New Jersey 01701-1709, USA
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Affiliation(s)
- M T Brandt
- Division of Oral and Maxillofacial Surgery, University of Kentucky College of Dentistry, Lexington, KY 40536-0297, USA
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Affiliation(s)
- E R Crouch
- Department of Ophthalmology, Eastern Virginia Medical School, Norfolk 23502-3990, USA
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Rahmani B, Jahadi HR. Comparison of tranexamic acid and prednisolone in the treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1999; 106:375-9. [PMID: 9951493 DOI: 10.1016/s0161-6420(99)90079-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Oral antifibrinolytics, oral steroids, and no oral treatment are the preferred medical treatments for traumatic hyphema. Antifibrinolytics and steroids have decreased the chance of rebleeding in some studies but failed to alter the clinical course in others. Rate of secondary hemorrhage seems variable among different geographic and ethnic groups of patients. Comparison of the treatments in each population is necessary to document the most effective method of preventing recurrent hemorrhage. DESIGN Randomized, placebo-controlled, clinical trial. PARTICIPANTS Two hundred thirty-eight patients in whom hyphema developed after a blunt trauma entered the study. INTERVENTION Eighty patients received 75 mg/kg per day oral tranexamic acid (TA) divided into 3 doses, 80 patients received a placebo with the same number of tablets and frequency as those of the TA group, and 78 patients received 0.75 mg/kg per day oral prednisolone divided into 2 doses. MAIN OUTCOME MEASURE Secondary hemorrhage during the hospital course was measured. RESULTS Secondary hemorrhage occurred in 8 patients (10%) of the TA group, 14 patients (18%) of the prednisolone group, and 21 patients (26%) of the placebo group. The difference between the incidence of rebleeding between TA and placebo groups was statistically significant (P = 0.008). Patients receiving a placebo had a greater chance of secondary bleeding than did patients receiving TA (odds ratios = 3.2; 95% confidence interval = 1.3, 7.5). The incidences of rebleeding were not significantly different in placebo versus prednisolone groups (P = 0.21) and TA versus prednisolone groups (P = 0.15). CONCLUSION In a population with a high rate of secondary bleeding, TA is more effective than oral prednisolone or no oral treatment in preventing rebleeding among patients with traumatic hyphema.
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Affiliation(s)
- B Rahmani
- Department of Ophthalmology, Shiraz University of Medical Sciences, Iran
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Rahmani B, Jahadi HR, Rajaeefard A. An analysis of risk for secondary hemorrhage in traumatic hyphema. Ophthalmology 1999; 106:380-5. [PMID: 9951494 DOI: 10.1016/s0161-6420(99)90080-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Factors such as size of hyphema, intraocular pressure, initial visual acuity, and use of steroids or antifibrinolytic drugs may be associated with the likelihood of rebleeding in traumatic hyphema. The association of the visual outcome with secondary hemorrhage has been questioned. DESIGN Randomized, placebo-controlled, clinical trial. PARTICIPANTS Two hundred and thirty-eight patients who had hyphema develop after blunt trauma. INTERVENTION Eighty patients received oral tranexamic acid, 80 patients received placebo, and 78 patients received oral prednisolone. MAIN OUTCOME MEASURES Secondary hemorrhage and vision at the time of discharge from the hospital were measured. RESULTS Rebleeding occurred in 43 (18%) of the patients and was prevented significantly by oral tranexamic acid compared with the placebo (odds ratios [OR] = 0.39; 95% confidence interval [CI], 0.17, 0.89). Occurrence of secondary hemorrhage had weak associations with initial high intraocular pressure (OR = 2.7; 95% CI, 0.99, 7.3) and initial visual acuity of 6/60 or less (OR = 1.8; 95% CI, 0.9, 3.7). Secondary hemorrhage had no statistical association with age, gender, oral prednisolone, size of hyphema, and retinal damage. Visual acuity of 6/60 or less at the time of discharge was significantly associated with rebleeding (OR = 10.5; 95% CI, 3.7, 29.2), initial visual acuity of 6/60 or less (OR = 9.9; 95% CI, 2.8, 38.0), retinal damage (OR = 14.6; 95% CI, 3.8, 55.8), and male gender (OR = 6.5; 95% CI, 1.4, 31.9). Final visual acuity had no significant statistical association with age, use of oral prednisolone or tranexamic acid, and size of hyphema. CONCLUSIONS High intraocular pressure and low vision at the time of first examination may be associated with increased chance of rebleeding. Retinal damage, secondary hemorrhage, male gender, and initial poor vision are associated with a worse visual outcome in patients with traumatic hyphema.
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Affiliation(s)
- B Rahmani
- Department of Ophthalmology, Shiraz University of Medical Sciences, Iran
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Abstract
OBJECTIVE To present a child with an unrecognized microscopic traumatic hyphema and acute glaucoma who was initially treated as a closed head injury patient. DESIGN Case report and discussion. RESULTS Symptoms attributable to unrecognized occult ocular injury in a child with sickle cell trait resulted in evaluation and treatment of the child for a closed head injury. Evaluation included a computed tomography scan of the head and lumbar puncture. An ophthalmologic consultation later revealed a microscopic hyphema and acute glaucoma as the etiology of the child's signs and symptoms. CONCLUSIONS Children who present with neurologic symptoms and a history of ocular trauma should undergo an ophthalmologic examination as soon as possible. Hyphema, even if not readily visible on physical examination, can result in the development of acute glaucoma with signs and symptoms that resemble a closed head injury.
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Affiliation(s)
- D K Coats
- Cullen Eye Institute, Baylor College of Medicine, Texas Children's Hospital, Houston 77030, USA
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27
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Nasrullah A, Kerr NC. Sickle cell trait as a risk factor for secondary hemorrhage in children with traumatic hyphema. Am J Ophthalmol 1997; 123:783-90. [PMID: 9535622 DOI: 10.1016/s0002-9394(14)71127-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine risk factors for secondary hemorrhage and poor visual outcome in children with traumatic hyphemas. METHODS We reviewed 99 eyes of 97 children younger than 18 years who had been hospitalized for hyphema within 48 hours of blunt eye trauma. Inpatient records were examined for race, age, sickle cell trait status, size of hyphema and intraocular pressure at admission, secondary hemorrhage (rebleed of hyphema), and medications while hospitalized. Fifty-five eyes of 53 children had at least 1 month of follow-up or attained best-corrected visual acuity of 20/50 or better at their last outpatient visit. RESULTS Among 99 eyes of 97 children with traumatic hyphema, secondary hemorrhage occurred in nine eyes (9%). Among 72 eyes of 70 African-American children, secondary hemorrhage occurred in nine eyes (14%), whereas in 27 eyes of 27 white children, there were no secondary hemorrhages. However, when the 14 eyes of 13 sickle cell trait-positive children were excluded from the African-American group, the 57 eyes of sickle cell trait-negative African-American and white children did not have any secondary hemorrhages. The sickle cell trait-positive group had secondary hemorrhages in nine of 14 eyes (64%), significantly (P < .005) different from the 0% rate in the 57 eyes of African-American sickle cell trait-negative and white children. The sickle cell trait-positive group also had higher intraocular pressure and permanent visual impairment. CONCLUSION Sickle cell trait is a significant risk factor for secondary hemorrhage, increased intraocular pressure, and permanent visual impairment in children who have traumatic hyphemas following blunt trauma.
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Affiliation(s)
- A Nasrullah
- Department of Ophthalmology, University of Tennessee, Memphis 38163, USA
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Hemphill RR, Doe EA. Clinical pearls. Right eye pain and redness. Acad Emerg Med 1997; 4:142-3, 147-9. [PMID: 9043543 DOI: 10.1111/j.1553-2712.1997.tb03722.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- R R Hemphill
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX 78234-6200, USA
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Teboul BK, Jacob JL, Barsoum-Homsy M, Brunette I, Chevrette L, Milot J, Orquin J, Polomeno RC, Quigley MG. Clinical evaluation of aminocaproic acid for managing traumatic hyphema in children. Ophthalmology 1995; 102:1646-53. [PMID: 9098257 DOI: 10.1016/s0161-6420(95)30814-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The purpose of this study is to determine the incidence of secondary hemorrhage after traumatic hyphema in children and to evaluate the efficacy of epsilon aminocaproic acid in reducing this incidence. METHODS In a prospective, randomized, double-blind study performed between November 1987 and February 1994, 94 children admitted for traumatic hyphema were assigned to receive either aminocaproic acid (n = 48) (100 mg/kg every 4 hours; maximum, 30 g daily) or placebo (n = 46) for 5 days. Patients who had ingested aspirin in the week preceding admission were excluded from the study. RESULTS Mean age of the patients was 9.4 years. Black patients comprised 4% of the study population. Secondary hemorrhage occurred in only three patients (3.2%), two from the placebo group and one from the aminocaproic acid group, none of whom had any complications. The duration of hospital stay and the clot resorption times were increased significantly in the aminocaproic acid group (P < 0.001). CONCLUSIONS The authors report a very low incidence of secondary hemorrhage compared with most previous studies. This difference is likely related to the small proportion of black patients in our study and to the exclusion of patients having ingested aspirin, two factors that seem to be associated with higher rates of rebleeding. The efficacy of aminocaproic acid could not be determined due to the low incidence of hemorrhage. The results of this study, however, suggest that the incidence of secondary hemorrhage in white patients without prior ingestion of aspirin is insufficient to justify routine use of aminocaproic acid in managing traumatic hyphema. Rather, an individualized decision based on the risk factors of each patient would seem more appropriate to avoid a slower clot resorption time and possible side effects of this medication.
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Affiliation(s)
- B K Teboul
- Department of Ophthalmology, St. Justine's Hospital, University of Montreal, Quebec, Canada
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Fong LP. Secondary hemorrhage in traumatic hyphema. Predictive factors for selective prophylaxis. Ophthalmology 1994; 101:1583-8. [PMID: 8090460 DOI: 10.1016/s0161-6420(94)31134-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Treatment to decrease the rebleeding rate in traumatic hyphema remains controversial. Although antifibrinolytics recently have been shown to reduce secondary hemorrhage rates, their routine use has not been widely applied because of adverse side effects and the relatively low frequency of severe hyphema complications. Alternatively, their use may be restricted to patients at high risk, but prognostic factors for rebleeding have not been clearly identified. METHODS From a prospective ocular trauma survey, 371 patients with traumatic hyphema were identified, and Fisher's exact test was applied to test for significant differences between patients who did and did not rebleed for various characteristics. Significant factors contributing to rebleeding were fitted into a multiple logistic regression model, and odds ratios (OR) and 95% confidence intervals (95% CI) were calculated. RESULTS Secondary hemorrhage occurred in 8% of patients and was significantly more frequent in those with visual acuities of 20/200 or less (OR = 3.1; 95% CI = 1.3,7.5), initial hyphema more than one third of the anterior chamber (OR = 2.8; 95% CI = 0.9,8.0), delayed medical attention more than 1 day after injury (OR = 2.9; 95% CI = 1.0,8.4), and elevated intraocular pressure at time of first examination (OR = 2.9; 95% CI = 1.1,7.9). The secondary hemorrhage rate rose from 5% without any of these specified factors to 15% with at least one factor present. No statistical associations were found for age, injury-related iris abnormalities, or aspirin usage. CONCLUSION Using multivariate logistic regression in populations with low rates of secondary hemorrhage, a predictive model may be used to categorize patients who have higher rebleeding rates, for whom possible benefits may outweigh the risks of prophylactic treatment, and those with lower rebleeding rates, who may not necessarily benefit from treatment.
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Affiliation(s)
- L P Fong
- Department of Ophthalmology, University of Melbourne, Victoria, Australia
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Ng CS, Sparrow JM, Strong NP, Rosenthal AR. Factors related to the final visual outcome of 425 patients with traumatic hyphema. Eye (Lond) 1992; 6 ( Pt 3):305-7. [PMID: 1446766 DOI: 10.1038/eye.1992.60] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A retrospective study of the visual outcome of 425 in-patients with traumatic hyphaema has been conducted. A multivariate analysis demonstrated that after adjusting for age, sex and pre-existing poor vision, the size of hyphaema on presentation and the presence of retinal damage were significant predictors of a worse final visual outcome (p = 0.00003 and 0.00001 respectively). Topical steroid and/or cycloplegic medication, and the occurrence of secondary haemorrhage did not influence the final visual outcome after adjustment for the other variables. These data illustrate, in an unselected sequential population of patients, the role of these factors in terms of final visual outcome following hyphaema from blunt ocular trauma.
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Affiliation(s)
- C S Ng
- Department of Ophthalmology, Leicester Royal Infirmary
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Ng CS, Strong NP, Sparrow JM, Rosenthal AR. Factors related to the incidence of secondary haemorrhage in 462 patients with traumatic hyphema. Eye (Lond) 1992; 6 ( Pt 3):308-12. [PMID: 1446767 DOI: 10.1038/eye.1992.61] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In a retrospective study of 462 in-patients with traumatic hyphema, secondary haemorrhage occurred in 8.7% of patients. A multivariate analysis demonstrated that the size of hyphaema on presentation and the presence of retinal damage did not affect the probability of secondary haemorrhage. The incidence of secondary haemorrhage was found to decrease by approximately half with the use of topical steroid (p = 0.005), but did not appear to be influenced by the use of cycloplegics. These data indicate in an unselected sequential population of patients, the therapeutic importance of topical steroid in the treatment of blunt ocular trauma.
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Affiliation(s)
- C S Ng
- Department of Ophthalmology, Leicester Royal Infirmary
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Volpe NJ, Larrison WI, Hersh PS, Kim T, Shingleton BJ. Secondary hemorrhage in traumatic hyphema. Am J Ophthalmol 1991; 112:507-13. [PMID: 1951586 DOI: 10.1016/s0002-9394(14)76850-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We analyzed the records of 132 patients hospitalized between July 1986 and February 1989 for management of traumatic hyphema. The incidence of secondary hemorrhage was compared between patients treated with or without systemic administration of aminocaproic acid in addition to an otherwise identical protocol. Results among patients who were examined within one day of injury disclosed a 4.8% secondary hemorrhage rate in aminocaproic acid-treated patients (three of 63 patients) compared with a 5.4% rate in the patients not treated with aminocaproic acid (three of 56 patients, P = .31). All six patients sustaining secondary hemorrhage recovered visual acuities of 20/40 or better, with five of six patients achieving 20/20 visual acuities. A separate group of 13 patients who were examined more than one day after injury were found to have a secondary hemorrhage rate of 38.5% (five of 13 patients). Macular injury, not secondary hemorrhage, was most often responsible among those patients suffering permanent visual loss. In this study of a predominantly white population, patients had a relatively low incidence of secondary hemorrhage and did not demonstrate detectable benefit from aminocaproic acid administration. Because of the recognized side effects and cost of treatment, further analysis to determine which patients will benefit from treatment with aminocaproic acid is indicated.
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Affiliation(s)
- N J Volpe
- Eye Emergency Department, Massachusetts Eye and Ear Infirmary, Boston
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Abstract
A retrospective study was made of 314 consecutive cases of traumatic hyphaema in a mixed urban and rural Scottish population. Secondary haemorrhage occurred in 4.1% of cases and was not associated with a worsening of final visual acuity. There were no identifiable risk factors for secondary haemorrhage. Poor visual outcome was in most cases attributable to retinal pathology. The use of antifibrinolytic agents does not appear to be necessary in such a population, and the importance of detecting associated retinal detachment is emphasised.
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Affiliation(s)
- P Kearns
- Princess Alexandra Eye Pavilion, Edinburgh
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Farber MD, Fiscella R, Goldberg MF. Aminocaproic acid versus prednisone for the treatment of traumatic hyphema. A randomized clinical trial. Ophthalmology 1991; 98:279-86. [PMID: 2023746 DOI: 10.1016/s0161-6420(91)32299-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
One hundred twelve patients who sustained hyphema after blunt trauma were enrolled in a double-blind randomized clinical trial to determine the relative efficacies of aminocaproic acid (Amicar) and systemic prednisone for reducing the rate of secondary hemorrhage. Fifty-six patients received an oral dosage of 50 mg/kg of aminocaproic acid every 4 hours for 5 days, up to a maximum of 30 g daily, and 56 patients received an oral dosage of 40 mg of prednisone daily (adjusted for weight) in two divided doses. Placebo pills and liquids were given to each patient to mask the treatment schedules. There were no statistically significant differences between the patient populations for any demographic or clinical characteristic (e.g., visual acuity, intraocular pressure [IOP], initial hyphema size) measured in the study. Blacks comprised 53% of the study population, and the mean age of the patients was 23.5 years. Four patients in each of the treatment groups experienced a secondary hemorrhage; the rebleed rate was 7.1% in each group.
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Affiliation(s)
- M D Farber
- Department of Ophthalmology, University of Illinois, Chicago 60612
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Affiliation(s)
- J N Bloom
- Children's Hospital, St Louis, Missouri
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