Traumatic Hyphaema Iridocyclitis Management Guidelines (13)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

In addition to bilateral ocular injury, blunt or lacerating trauma can cause a wide range of intracranial or periocular injuries that may need prompt assessment and treatment. 

 

History

  • Mechanism of injury
  • Details of object causing trauma
  • Change in VA since injury
  • Ocular symptoms following injury
  • Complete medical and ophthalmic history
  • Associated ocular, neurological and systemic symptoms 

Examination

Complete ocular examination is necessary in all cases and should include:

  • Visual acuity
  • Pupil reaction / RAPD - Use consensual response if necessary
  • IOP
  • RBCs in AC and hyphaema height if present
  • Exclude globe rupture – see separate guidelines for clinical features. Includes:
    • Shallow anterior chamber
    • Difference in IOP between eyes
  • Corneal blood staining 

Investigations to be performed as appropriate

BP 

Bloods: 

  • FBC/Coag/INR - if blood dyscrasia suspected or on warfarin/antiplatelet therapy
  • LFT if liver disease suspected 
  • U&E if systemic treatment to lower IOP or surgical intervention anticipated 

B-scan 

  • Exclude posterior segment injury or intraocular foreign body if no fundal view 

!Caution - do not compress globe when performing B-scan or perform gonioscopy or scleral indentation in the acute setting!

Management

There is no evidence that any drug or non-drug intervention currently reported in the literature alters final VA outcome. See next sections for treatment options that can be considered on an individual basis. Check contraindications for all medications.

Clinical photographs

Take clinical photographs if possible and if time permits

Management of Hyphaema without other ocular injury

Non-drug Interventions

  • Minimal Activity - at least 2 week duration. No lifting / straining.
  • Avoid lying flat for prolonged periods - sleep with head elevated 30-45%
  • Clear eye shield - when asleep at night and when traveling outside

Drug Interventions

In the presence of uveitis or photophobia consider:

  • Prednisolone acetate 1% up to x6 daily
  • Cyclopentolate 1% x3 daily

There is no evidence to support the use of an antifibrinolytic agent.

Analgesia:

  • Simple analgesia as required – Paracetamol/Co-Codamol
  • Avoid NSAIDs or analgesia that may induce nausea or vomiting

Management of Raised IOP

20-30mmHg

  • Timolol maleate 0.5% x2 daily

30-35mmHg

  • Brinzolamide-timolol (Azarga) x2 daily (stop timolol if previously on this)

>35mmHg

  • Brinzolamide-timolol (Azarga) x2 daily
  • Acetazolamide SR 250mmHg

Theoretical risk of prostaglandin analogues inducing further inflammation.

IOP can be difficult if sickle cell or poor clotting tendency – discuss with senior.

Consider Admission

  • >75% hyphaema
  • Significantly IOP on presentation >50mmHg or uncontrolled on treatment >35mmHg
  • Known bleeding disorder
  • Unable to attend for daily review / concern over failure to reattend
  • Concern over compliance with treatment and limited activity 

When to Consider Surgical Intervention - Discuss with Senior

  • Corneal blood staining or uncontrolled IOP over 50mmHg
  • Hyphaema:
    • 100% hyphaema or unresolving and >75% by 4 days
    • Failure to reduce to <50% by 1 week
  • Lower threshold of the above in patients with sickle cell

Follow up

Hyphaema present

  • Review in ARC on daily basis until resolved.  Discuss with senior if still present after 3 days.  If resolves refer to microhyphaema.

Microhyphaema

  • Review in ARC within 4 days if IOP normal then 1 week later if IOP remains normal.  Routine clinic review thereafter until resolution.

Elevated IOP

  • Discuss with senior if uncontrolled on above treatment.

Routine clinic follow up will be necessary for all patients for gonioscopy and fundal examination once hyphaema has resolved.

Patient should be advised to return to ARC urgently if there is a sudden reduction in VA, increase in pain, or development of new symptoms suggestive of secondary haemorrhage.

 

Last reviewed: 22 June 2022

Next review: 30 June 2024

Author(s): Alan Cox

Version: 5

Author Email(s): [email protected]

Co-Author(s): Douglas Lyall

Approved By: Medicines Utilisation Subcommittee of ADTC

Document Id: 13