60.8 Bleeding into an injured eye

Bleeding from a patient’s iris into his anterior chamber (hyphaema) is common, and can occur immediately after the injury, or not for some hours or days. It can be mild, or it can fill his anterior chamber with blood. The blood may clot and obscure his anterior chamber completely, or it may occasionally form a fluid level as in C, and D, Fig. 60-7. The tear in his iris (which may be obscured by blood) can be partial or complete.

The patient complains of poor vision after a blunt injury. When you examine him, you may see: (1) Only a diffuse reddish haze in his anterior chamber. (2) A settled layer of blood. (3) His anterior chamber so full of blood that you can see nothing behind it. His eye may feel abnormally hard or soft.

Fortunately, bleeding into the anterior chamber usually stops spontaneously, but in 20% of cases it starts again during the following week. If it does start again, it is likely to be more severe than after the original injury. A hyphaema is not an acute emergency, so that you usually have a week in which to see if it is going to absorb, and in which to refer the patient. Meanwhile, give him acetazolamide to keep the pressure is his globe low, and reduce the chance of secondary glaucoma, which is the major complication. Operating on a hyphaema is an expert task and results are often not good.

There is little you or anyone else can do for bleeding into the vitreous of the posterior chamber, so pad both the patient’s eyes and put him to bed.

BLEEDING INTO THE EYE

This extends the general method for an eye injury in Section 60.1

If the patient is a reliable adult with minimal hyphaema, ask him to rest quietly at home.

If his hyphaema is more than minimal, admit him, and put him to bed with his trunk raised at 30°. This will lower the venous pressure in his head and thus his intraocular pressure. If you can see through his pupil, examine his fundus for vitreous haemorrhage and other damage.

Sedate him. Pad both his eyes. Give him acetazolamide 250 mg 6 hourly. Don’t give him any eye drops. Ask him to avoid moving his head, and especially to avoid bending down. Monitor the tension in his globe carefully. The blood usually absorbs in a few days; if it does, you can discharge him.

If bleeding starts again, keep him in bed for a further week from the time of the bleed. If he has a massive further bleed causing an almost black hyphaema, and making his eye hard and his cornea oedematous, the blood in his eye needs evacuating urgently.

If the blood does not absorb in a week, refer him.

If the tension in his globe rises, he may be developing secondary glaucoma. Control it with acetazolamide 500 mg initially, and 250 mg 6 hourly. If he does not improve after two days, refer him because he may need paracentesis of his anterior chamber.