Comparative Study

Authors: Laura Armonaite, Anders Behndig

PURPOSE

To assess Uveitis-Glaucoma-Hyphaema syndrome (UGH syndrome) with focus on resolution, glaucoma development and risk factors.

METHODS

This retrospective case-control study with a cross-sectional component was performed to compare three groups with 71 patients each: UGH syndrome, dislocated intraocular lens (IOL) without UGH syndrome and ordinary pseudophakia. Main outcome measures were resolution of the UGH syndrome, best-corrected visual acuity (BCVA) and the need of glaucoma therapy. We also assessed the IOL-iris contact signs and the use of blood thinners.

RESULTS

Uveitis-Glaucoma-Hyphaema (UGH) syndrome resolved in 77 % of patients who underwent various kind of IOL surgery. Intraocular pressure (IOP) decreased and BCVA improved in the operated cases (p = 0.02 and p < 0.001, respectively), but not in the cases treated conservatively. Intraocular pressure (IOP) ≥22 mmHg at the first haemorrhage predicted the need of glaucoma therapy after UGH syndrome resolution (p = 0.002, area under the curve = 0.8). Fifty-one per cent of patients without preexisting glaucoma needed glaucoma therapy after UGH syndrome resolution. Pseudophacodonesis was seen more frequently in the UGH group than in the ordinary pseudophakia group (p = 0.001). Iris defects were not more frequent in the UGH group than in the Dislocated group but the types of defects differed (p < 0.0001). Blood thinners were not more frequent in UGH.

CONCLUSION

In UGH syndrome, the results are better with surgical intervention than with conservative treatment, but surgery does not guarantee resolution. Pseudophacodonesis is a risk factor for UGH syndrome, but blood thinners are not, and iris defects are not specific to UGH syndrome. A high IOP at the first haemorrhage increases the risk for needing subsequent IOP-lowering therapy.

Topics: Adult; Aged; Aged, 80 and over; Case-Control Studies; Disease Management; Female; Glaucoma; Humans; Hyphema; Male; Middle Aged; Prognosis; Retrospective Studies; Risk Factors; Syndrome; Uveitis

PubMed: 32511897
DOI: 10.1111/aos.14477

Review

Authors: Virgilio Galvis, Alejandro Tello, Néstor I Carreño...

Massive hyphaema presentation after a laser iridotomy is very rare. We report a 63-year-old man with ischaemic heart disease on dual antiplatelet therapy (aspirin plus ticagrelor) who was diagnosed as a primary angle-closure suspect and was to undergo a neodymium-doped yttrium aluminium garnet laser iridotomy at Centro Oftalmológico Virgilio Galvis, Floridablanca, Colombia in 2016. While performing the iridotomy in the left eye, active bleeding occurred that finally filled approximately 75% of the anterior chamber. Intraocular pressure (IOP) increased to 62 mmHg. Mannitol and a topical dorzolamide/timolol were used to control the increase in IOP. The hyphaema slowly resolved over the following week without . This case revealed that massive hyphaema can complicate laser iridotomy in patients on dual antiplatelet therapy, although this is rare. Therefore, if patients are taking aspirin and ticagrelor, it would be advisable to stop the second medication if possible. In addition, sequential application of photocoagulation and photodisruption lasers might diminish the risk of significant bleeding.

Topics: Aspirin; Colombia; Glaucoma, Angle-Closure; Humans; Hyphema; Iridectomy; Laser Therapy; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Ticagrelor

PubMed: 31198598
DOI: 10.18295/squmj.2019.19.01.012

Authors: Kenneth G J Ooi, Rohan Gupta, Sarah B Wang...

BACKGROUND

Iris vascular tufts are rare iris stromal vascular hamartomas. Patients with iris vascular tufts generally remain asymptomatic until presenting with a spontaneous hyphaema or with mild intraoperative pupil margin haemorrhage during anterior segment surgery. This is the first reported case of spontaneous hyphaema from iris vascular tuft related to a documented supratherapeutic International Normalised Ratio as a predisposing factor. At 86 years of age, this patient also represents the oldest documented first occurrence of bleeding from an iris vascular tuft.

CASE PRESENTATION

An 86 year old Caucasian lady presented with sudden and persisting loss of vision in her right eye, ocular pain and vomiting. She had a supratherapeutic International Normalised Ratio of 3.9 related to Warfarin use. Her intraocular pressure in the right eye was raised at 55 mmHg, with a 1.6 mm hyphaema and multiple iris vascular tufts visible around the entire pupil.

CONCLUSION

The present case highlights the risk of anticoagulation therapy as a predisposing factor for spontaneous hyphaema and adds to the management considerations for this condition. It also demonstrates the need for Ophthalmologists to be aware of iris vascular tufts as a cause for spontaneous hyphaema, independent of age and systemic associations.

Topics: Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Atropine; Eye Hemorrhage; Female; Glucocorticoids; Hamartoma; Humans; Hyphema; International Normalized Ratio; Iris Diseases; Mydriatics; Ophthalmic Solutions; Prednisolone; Pulmonary Embolism; Warfarin

PubMed: 26071139
DOI: 10.1186/s12886-015-0050-y

Authors: Mustafa Iftikhar, Tahreem Mir, Natalie Seidel...

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.

Topics: Adolescent; Adult; Aged; Child; Eye Injuries; Female; Humans; Hyphema; Intraocular Pressure; Male; Middle Aged; Recurrence; Retrospective Studies; Visual Acuity; Wounds, Nonpenetrating; Young Adult

PubMed: 33124159
DOI: 10.1111/aos.14603

Review

Authors: Mihail Zemba, Georgiana Camburu

Uveitis-Glaucoma-Hyphaema Syndrome (UGH syndrome, or "Ellingson" Syndrome) is a rare condition caused by the mechanical trauma of an intraocular lens malpositioned over adjacent structures (iris, ciliary body, iridocorneal angle), leading to a spectrum of iris transillumination defects, microhyphaemas and pigmentary dispersion, concomitant with elevated intraocular pressure (IOP). UGH Syndrome can also be characterized by chronic inflammation, secondary iris neovascularization, cystoid macular edema (CME). The fundamental step in the pathogenesis of UGH syndrome appears to arise from repetitive mechanical iris trauma by a malpositioned or subluxed IOL. These patients have uncomplicated cataract implants and return for episodes of blurry vision weeks to months after surgery. This may be accompanied by pain, photophobia, erythropsia, anterior uveitis, hyphaema along with raised intraocular pressure. A careful history and examination, as well as appropriate investigations can confirm the diagnostic. Treatment options are IOL Explantation exchange, topical and systemic medication, and cyclophotocoagulation, the placement of a Capsular Tension Ring to redistribute zonular tension and Anti-vascular endothelial growth factor (anti-VEGF) Therapy.

Topics: Angiogenesis Inhibitors; Artificial Lens Implant Migration; Device Removal; Glaucoma; Humans; Hyphema; Iris; Laser Coagulation; Lens Implantation, Intraocular; Macular Edema; Neovascularization, Pathologic; Syndrome; Uveitis

PubMed: 29450365
DOI: 10.22336/rjo.2017.3

Authors: Alex P Schenk, Ann M McGrath, Cheryl A Beatty...

OBJECTIVE

To determine incidence and risk factors of post-sterilization hyphema in shelter cats.

ANIMALS STUDIED

Retrospective medical record review of 1204 cats and prospective screening of 195 cats.

PROCEDURES

The study consisted of three parts: (a) Survey responses were collected from 20 veterinarians, who perform high-quality high-volume spay-neuter (HQHVSN) in both shelter and public clinic settings; (b) medical records of 1204 cats were analyzed retrospectively over a 14-month time period; and (c) ophthalmic examinations, including tonometry, were performed prospectively on 195 cats before and after sterilization surgery over 8 weeks.

RESULTS

Nine of 20 surveyed veterinarians reported having witnessed hyphema in cats following sterilization surgery. Retrospective review of 1204 medical record and prospective screening of 195 cats showed that three juvenile (<1 year of age) male cats (<2 kg) developed hyphema within 1 hour following surgery (0.2% incidence). In all three affected cats, anesthesia was induced with tiletamine/zolazepam (3 of 523 cats induced with this drug combination; 0.6% incidence), and hyphema resolved within 20 hours. Mean intraocular pressures as measured by Icare® TonoVet were (mean ± standard deviation) 11.5 ± 3.8 mm Hg and 21.7 ± 4.6 mm Hg for juvenile (<1 year of age) and adult (>1 year of age) cats, respectively.

CONCLUSIONS

Survey responses and three observed cases confirm the existence of feline post-sterilization hyphema with an estimated incidence of 0.2%. The underlying mechanism for this occurrence remains unknown.

Topics: Animals; Cats; Female; Hyphema; Hysterectomy; Incidence; Male; Michigan; Orchiectomy; Ovariectomy; Postoperative Complications; Prospective Studies; Records; Retrospective Studies

PubMed: 32216041
DOI: 10.1111/vop.12760

Authors: I-Hung Lin, Lung-Chi Lee, Ke-Hao Huang...

: This study introduces a novel office-based procedure involving air-blood exchange under a slit-lamp microscope for treatment of severe hyphema after filtering surgery. : This retrospective study enrolled 17 patients (17 eyes) with a diagnosis of primary open-angle glaucoma with severe hyphema (≥4-mm height) after filtering surgery. All patients were treated with air-blood exchange under a slit-lamp using room air (12 patients) or 12% perfluoropropane (C3F8; five patients). : The procedures were successful in all 17 patients; they exhibited clear visual axes without complications during follow-up. In the room air group, the mean visual acuity (VA) and hyphema height significantly improved from 1.70 ± 1.07 LogMAR and 5.75 ± 1.14 mm before the procedure to 0.67 ± 0.18 LogMAR and 2.83 ± 0.54 mm after the procedure ( = 0.004; < 0.001). In the C3F8 group, the mean VA showed a trend, though not significant, for improvement from 1.70 ± 1.10 LogMAR to 0.70 ± 0.19 LogMAR ( = 0.08); the mean hyphema height showed a trend for improvement from 5.40 ± 0.96 mm to 3.30 ± 0.45 mm. Compared with the C3F8 group, the room air group showed the same efficacy with a shorter VA recovery time. : "Air-blood exchange under a slit-lamp using room air" is a convenient, rapid, inexpensive, and effective treatment option for severe hyphema after filtering surgery, and may reduce the risk of failure of filtering surgery.

Topics: Filtering Surgery; Glaucoma; Glaucoma, Open-Angle; Humans; Hyphema; Intraocular Pressure; Retrospective Studies; Trabeculectomy

PubMed: 34441061
DOI: 10.3390/medicina57080855

Authors: Virgilio Galvis, Angelica Pedraza-Concha, Alejandro Tello...

To analyze clinical features, treatment, and results of patients with non-penetrating traumatic hyphema in an ophthalmological center in Colombia. A retrospective cohort study in which medical records of patients with traumatic hyphema were analyzed between 2013 and 2018. 38 eyes of 37 patients (34 men, 3 women) were included. Average age was 30.6 ± 16.6 years. Sports-related (42.1%) and occupational accidents (34.2%) were the main causes. 67.5% of the eyes had grade I hyphema. 95% received topical corticosteroids, 92.1% topical mydriatics and 52.63% ocular hypotensive eyedrops. Two eyes with hyphema grade I did not receive steroids and resolved uneventfully. None of the eyes rebleeded, even without antifibrinolytics. One patient with grade IV hyphema required surgery. Mean hyphema's clearance time was 8.4 ± 3.2 days. The last mean corrected distance visual acuity was LogMAR 0.25. There were no complications directly related to the hyphema. Working related activities were the second cause of traumatic hyphema in our cohort, which might be attributable to poor awareness of the importance or ocular protection, or limited access to recommended protective devices. Outpatient management enabled adequate outcomes. Corticosteroids and mydriatics were the treatment cornerstone, though seemed not to be imperative when hyphema was grade I. We were not able to support the contributive role from antifibrinolytics, because none of our patients rebleeded in spite of the absence of them. IOP = intraocular pressure, AC = anterior chamber, CDVA = corrected distance visual acuity.

Topics: Administration, Ophthalmic; Adolescent; Adult; Antihypertensive Agents; Colombia; Eye Injuries; Female; Glucocorticoids; Humans; Hyphema; Intraocular Pressure; Male; Middle Aged; Mydriatics; Retrospective Studies; Treatment Outcome; Visual Acuity; Wounds, Nonpenetrating; Young Adult

PubMed: 32292855
DOI: No ID Found

Authors: G W S Simanjuntak, G Farinthska, G A M Simanjuntak...

OBJECTIVE

: To report the risk factors for poor visual outcome in traumatic hyphema.

MATERIALS AND METHODS

A retrospective study was done by collecting data from medical records between January 2011 and December 2015 in Jakarta, Indonesia. Clinical data included initial visual acuity (IVA), final VA at 3 months, slit lamp evaluation with grading of hyphema, intraocular pressure, and fundus findings on direct or indirect ophthalmoscopy.

RESULTS

The study included 97 patients, with males showing a preponderance, the ratio being 9:1. Soft gun pellet was the most common cause (27.8%), others being workplace injuries (12.4%), sports injury (14.4%), traffic accident (2.1%), and other injuries (43.3%). Poor visual outcome was due to vitreous hemorrhage, cataract, iridodialysis, and choroidal rupture. On statistical analysis, significant risk factors were causality (P = 0.018), IVA (P = 0.026), onset of injury (0.000), and grade of hyphema (P = 0.000).

CONCLUSION

Grade of hyphema, IVA, causality, and onset of injury were significant risk factors related to poor visual outcome in traumatic hyphema.

Topics: Adolescent; Adult; Aged; Cataract; Choroid Hemorrhage; Eye Injuries; Female; Humans; Hyphema; Intraocular Pressure; Male; Middle Aged; Ophthalmoscopy; Paracentesis; Retrospective Studies; Risk Factors; Tonometry, Ocular; Vision Disorders; Visual Acuity; Wounds, Nonpenetrating; Young Adult

PubMed: 29984726
DOI: 10.4103/njcp.njcp_251_17

Meta-Analysis

Authors: Almutez Gharaibeh, Howard I Savage, Roberta W Scherer...

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.

Topics: Adrenal Cortex Hormones; Aminocaproic Acid; Antifibrinolytic Agents; Aspirin; Bandages; Bed Rest; Child; Estrogens, Conjugated (USP); Eye Injuries; Humans; Hyphema; Mydriatics; Patient Positioning; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Tranexamic Acid; Visual Acuity; Wounds, Nonpenetrating

PubMed: 30640411
DOI: 10.1002/14651858.CD005431.pub4