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| ARTICLES |
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| Year : 1978 | Volume
: 26
| Issue : 2 | Page : 32-34 |
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Management of traumatic hyphema
MR Chaddah, SP Gupta
Department of Ophthalmology, Medical College, Amritsar, India
Correspondence Address:
M R Chaddah
Department of Ophthalmology, Medical College, Amritsar
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 721240 
How to cite this article:
Chaddah M R, Gupta S P. Management of traumatic hyphema. Indian J Ophthalmol 1978;26:32-4 |
Hyphema, surgical or accidental, is a common ophthalmic problem. Various modes of treatment recommended are the use of eserine[12], pilocarpine[13], atropine[6], homatropine[16], anti-tubercular treatment[14] and hyalase, Diamox and vit. C[7]. A recent addition to the list has been the use of urokinase, a fibrinolytic enzyme, with which Stallard[15], Brodrick and Hall[1] and Rakusin[11] have claimed encouraging results.
This study was undertaken to determine the comparative efficacy of the various modes of treatment of hyphema and to assess the role of urokinase which has not been studied in this country.
| Materials & Methods | |  |
47 cases were included in this study. When they came under our observation, a special note was made on the cause of hyphema and the time elapsed between the injury and the appearance of blood in the anterior chamber. A thorough examination of the eye was carried out, the level of blood in the anterior chamber was noted with patient in sitting position and the visual acuity and intraocular tension were recorded. The cases were divided into the two major categories :
Group A (Medical Group): It included 24 cases. In these cases blood filled half or less than half of the anterior chamber. They were divided into three sub groups :
(i) 8 patients- chloramphenicol eye ointment twice a day.
(ii) 8 patients-4% pilocarpine drops and chloramphenicol eye ointment twice daily.
(iii) 8 patients-1% atropine eye ointment and chloramphenicol eye ointment twice a day.
All eyes were bandaged.
Group B (Surgical group) : It included 24 cases. In 23 of these cases blood filled more than half of the anterior chamber ; in one case blood filled less than half of the anterior chamber, but he had not responded to medical therapy. These cases were given surgical treatment and were divided into three sub. groups :
(i) 8 cases-paracentesis of the anterior chamber.
(ii) 8 cases-paracentesis and normal saline irrigation.
(iii) 8 cases urokinase was used to irrigate the anterior chamber. 5,000 Plough units were dissolved in 2 ml. of normal saline. 0.3 ml. of this solution was injected into the anterior chamber after paracentesis and dissolution of the clot observed. After 3 minutes the chamber was washed with normal saline. If the clot persisted the procedure was repeated upto a maximum of 5 times. If after this, the clot still remained, 0.3 ml. of the enzyme solution was left in the anterior chamber.
In all cases 1% chloramphenicol ointment was used and the eyes kept bandaged.
The immediate follow up lasted for a minimum of 10 days in the hospital and rate of absorption of blood, incidence of secondary bleeding, complications such as corneal staining, iritis, raised intra-ocular pressure, synechiae formation and visual acuity were noted.
Patients were followed up at weekly intervals for one month. The criteria used for comparison were the the rate of absorption of blood from the anterior chamber and the incidence of complications.
Results were classified as follows:
1. Cured-Total absorption of blood from the anterior chamber within 7 days without any sequelae.
2. Better-Absorption after 7 days but without sequelae.
3. Failure-Complications because of hyphema.
| Observations | | |
The various causes of hyphema encountered in this study are indicated in [Table - 1]. Majority of the cases followed surgery.
Rate of absorption of blood from the anterior chamber in group A was maximum in cases on 4% pilocarpine drops i.e. 1 to 5 days with an average of 3 days. Various complications which occurred in this group were secondary haemorrhage, iritis and secondary glaucoma.
In group B, the rate of absorption of hyphema was maximum on using urokinase i.e. 2 to 10 days with an average of 5 days. Various complications encountered in this group were secondary haemorrhage, iritis, secondary glaucoma, corneal staining and posterior synechiae. In cases with raised intraocular pressure surgical intervention helped in lowering the tension also. The decrease in tension occurred in maximum number of those cases which were treated with urokinase.
A comparative study of the success rate of different methods used showed that in the medical group it was maximum with the use of 4% pilocarpine and in the surgical group with the use of urokinase [Table - 2].
| Discussion | | |
High success rate in cases on pilocarpine in the medical group is attributed to the opening up of the angle with an increase in the facility of aqueous outflow. Moreover, pilocarpine increases the absorption of blood through the anterior surface of iris. On the contrary, atropine delays reabsorption of hyphema by embarrassing filtration due to a dilated pupil.
Secondary haemorrhage was observed in one case of the medical group, which was on pilocarpine Rakusinet[11] reported this complication in 6% of his cases on pilocarpine and 10% on chloramphenicol. Henry[5] experienced it with 11.5% of his cases on mydriatics.
Of this group, 3 cases developed iritis. This complication was also observed by Rakusin[11]
Raised intra-ocular tension was noted in only 3 cases of which 2 belonged to the group on pilocarpine. This was attributed to operative failure since both were cases of chronic simple glaucoma; third was on atropine locally.
Urokinase was the best method in the surgical group. It causes lysis of the blood clot, making it friable such that it is rapidly dispersed and absorbed[11]. Pados et al[8] stated that urokinase looses much of its effectiveness if the clot is too old; as was also observed by Brodrick and Hall' in 3 out of 14 of their cases; and in our one case where absorption was delayed for 10 days.
Paracentesis alone is better than with saline wash as chances of injury to lens and iris are diminished[3]. Moreover, saline irrigation is ineffective in clotted hyphema[10]
Secondary haemorrhage occurred in 12.5% of cases treated with paracentesis whereas Wilson et al[17] reported it in 7% of their cases. In urokinase group 12.5% of our cases had secondary haemorrhage as compared to 20% of the cases reported by Rakusin[11]. This bleeding is either from newly formed capillaries or originally lacerated vessels[4]. Temporary rise of intra-vascular pressure as in an unco-operative patient may be another clause[16].
Iritis occurred in 12.5% cases of paracentesis sub-group, 12.5% cases of urokinase sub-group and 25% cases of saline sub-group whereas Rakusin[11] reported in 19% of urokinase and 15% of saline group. Urokinase is very effective in lowering raised intra-ocular tension as observed in 6 of our 7 cases and 19 of 20 cases of Rakusin[11]
Corneal staining was seen in 3 cases of surgical group; one in each sub-group. All were having tension above 40 mm of Hg. and delayed absorption of hyphema to more than 8 days. Hence, corneal staining depends on the quantity of hyphema, rate of absorption and intra-ocular tension. According to Brodrick' corneal staining is greater in total secondary hyphema with raised tension.
| Summary | | |
47 cases of hyphema were treated by medical and surgical methods. It was found that in hyphema occupying less than one half of anterior chamber medical therapy with 4% pilocarpine is the treatment of choice whereas in large hyphema best results were obtained with urokinase.
| References | | |
| 1. | Brodrick, J.D. and Hall, R.D., 1971, Proc. Roy. Soc. Med., 64, 931.  |
| 2. | Brodrick, J.D., 1972, Brit. Jour. Ophthal., 56, 589. |
| 3. | Duke Elder, S., 1954, Text Book of Ophthal. 4, 5778, Henry Kimpton London. |
| 4. | Eagling, E.M., 1974, Brit. Jour. Ophthal. 58,126. |
| 5. | Henry, M.M., 1960, Amer. Jour. Ophthal. 49, 1298. |
| 6. | Laughlin, R.C., 1948, Tr. Pacific Coast O to Ophthal. Soc., 133. |
| 7. | Malik, S.R.K„ Gupta, A.K. and Gupta, O.K., 1969, Orient. Arch., Ophthal., 7,367. |
| 8. | Pados, S., Leibman, S. and Pollen, A., 1964, Arch. Ophthal., 71, 537. |
| 9. | Ploug, J. and Kjeldgaard, N.O., 1957, Biochem. et Biophys Acta., 24,278-quoted from Urokinase, Sept., 1972, p. 3, Leo Laboratories, Denmark. |
| 10. | Rakusin, W. and Kumming, B.S., 1969, S. Afr. Med. J., 43,638. |
| 11. | Rakusin, W., 1971, Brit. Jour. Ophthal., 55,826. |
| 12. | Rychner, R.O., 1944, I.A.M.A., 126,763. |
| 13. | Smith, H.E., Quoted by Oksala, A., 1967, Brit. Jour. Ophthal., 51,315. |
| 14. | Srivastva, K.N., Bhardwaj, P.C. and Mehta, C.M., 1969, Jour. of All India Ophthal. Soc., 17,273. |
| 15. | Stallard, H.B., 1965, Eye Surgery, 594, John Wright & Sons Ltd., Great Britain. |
| 16. | Thygeson, P. and Beard, C., 1952, Amer. Jour. Ophthal., 35,980. |
| 17. | Wilson, J.M., Mcker, T.P., Compbell, E.M. and Miller, G.E., 1954, Amer. Jour. Ophthal., 37,409. |
[Table - 1], [Table - 2]
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