Hyphema

Blood pooling in the front chamber of the eye, usually after blunt trauma. Rebleeding, high eye pressure, and corneal staining are the big concerns.

8 min read

When to seek emergency care

Go to the ER or be seen by an ophthalmologist the same day after any eye trauma - hyphema requires prompt evaluation to rule out an open-globe injury, monitor eye pressure, and start activity restrictions to prevent rebleeding (which is most dangerous in the first 3-5 days). Patients with sickle cell trait or disease are at especially high risk for pressure-related vision loss.

Seek immediate care if you experience:

Blood visible in the front of the eye (between the cornea and the iris) after any trauma
Eye pain, decreased vision, or sensitivity to light after a blow to the eye
Worsening pain or a new fall in vision in the days after an eye injury (possible rebleed or pressure spike)

Call 911 or go to the nearest emergency department for sudden vision loss, severe eye pain, or stroke-like symptoms.

Hyphema means blood has entered the anterior chamber, the fluid space between the cornea and iris. It is most commonly caused by blunt eye trauma, including sports injuries, falls, or assault. The visible blood is only part of the concern: eye pressure can rise, bleeding can recur during the first few days, and prolonged blood contact can cause corneal blood staining.

Key Takeaways

Hyphema is blood between the cornea and iris, sometimes just a thin layer, sometimes a full chamber
Blunt trauma is the usual trigger, including sports injuries, fights, falls, and projectile injuries
Rebleeding risk is highest in the first several days, so activity restriction is part of preventing complications
Eye pressure can rise quickly, and corneal blood staining can threaten vision
Sickle cell disease or trait changes the risk calculus, because pressure problems can be more dangerous
Follow-up checks matter, even if the eye looks better in the mirror

Medical illustration of a hyphema showing a horizontal layer of blood settled in the lower part of the anterior chamber of the eye with a visible fluid level in front of the iris

What Is Hyphema?

Anatomy

The anterior chamber is:

The space behind the cornea (clear front surface)
In front of the iris (colored part)
Filled with aqueous humor (clear fluid)

Grading

Hyphema is graded by how much of the anterior chamber is filled with blood:

Grade	Blood Level
Microhyphema	Suspended RBCs only, no layered blood
Grade I	Less than 1/3 of anterior chamber
Grade II	1/3 to 1/2 of anterior chamber
Grade III	More than 1/2 of anterior chamber
Grade IV (Total/8-ball)	Complete filling of anterior chamber

Causes

Traumatic (Most Common)

Blunt trauma: sports (especially baseball, basketball, racquet sports), fights, falls
Penetrating injuries: less common but more serious
Iatrogenic: after eye surgery

Non-Traumatic (Spontaneous)

Abnormal iris blood vessels (rubeosis from diabetes, vein occlusion)
Blood vessel abnormalities (juvenile xanthogranuloma, hemangioma)
Blood thinners (anticoagulants)
Bleeding disorders
Intraocular tumors
Herpes infection
After cataract surgery (UGH syndrome-uveitis, glaucoma, hyphema)

Spontaneous hyphema (without trauma) requires investigation for underlying cause.

Symptoms

What Patients Experience

Visible blood in the eye (may be noticed in mirror)
Blurred vision (varies with amount of blood)
Eye pain (often from associated inflammation or pressure elevation)
Light sensitivity (photophobia)
History of injury (in traumatic cases)

What the Doctor Sees

Blood layering in the anterior chamber (settles with gravity)
May be small (microhyphema) or filling entire chamber
Associated injuries (in trauma): abrasions, iris damage, lens problems

Initial Evaluation

Complete Eye Exam

Visual acuity: how much vision is affected
Intraocular pressure (IOP): often elevated
Slit lamp examination: details of hyphema and other injuries
Dilated exam: to check retina (if media clear enough)
Gonioscopy: to check drainage angle (often deferred initially)

Ruling Out Other Injuries

In traumatic hyphema, must evaluate for:

Open globe (surgical emergency)
Corneal abrasion
Iris damage
Lens dislocation
Retinal detachment
Orbital fracture

Special Testing

Ultrasound (if can't see inside due to blood): to rule out retinal detachment
Sickle cell screening: essential in at-risk populations
CT orbit: if concerned about fracture or foreign body

Sickle Cell Disease Consideration

Sickle cell disease/trait significantly increases risk of complications:

Red blood cells sickle in the low-oxygen anterior chamber
Sickled cells block drainage more effectively
Even mildly elevated IOP causes optic nerve damage
Certain medications (carbonic anhydrase inhibitors) are contraindicated
Ask about sickle cell disease or trait; testing is often considered for patients with personal/family history or ancestry from higher-prevalence populations

Treatment

Activity Restriction

Bed rest or limited activity: reduces risk of rebleeding
Head elevation (30-45 degrees): helps blood settle away from visual axis
No strenuous activity, bending, straining
Eye shield: protects from additional injury
No aspirin or NSAIDs: increases bleeding risk

Medications

Cycloplegics:

Dilate pupil and reduce ciliary spasm
Increase comfort
May reduce rebleeding

Topical Steroids:

Reduce inflammation
May reduce rebleeding risk
Use with caution (can raise IOP)

Aminocaproic Acid (Sometimes):

Antifibrinolytic agent
Reduces rebleeding risk
Side effects limit use
Generally reserved for higher-risk cases

IOP-Lowering Medications:

If pressure elevated
Avoid carbonic anhydrase inhibitors in sickle cell patients
Beta blockers, alpha agonists used instead

Surgical Intervention

Indications for surgical washout:

Corneal blood staining (developing or present)
IOP uncontrolled despite medications
Total (8-ball) hyphema not resolving
Earlier intervention in sickle cell patients

Procedures:

Anterior chamber washout (paracentesis)
Evacuation of clot
Possible irrigation

Complications

Elevated Intraocular Pressure

Blood cells clog trabecular meshwork (drainage system)
Can cause optic nerve damage (glaucoma)
Must be monitored closely
More dangerous in sickle cell patients

Rebleeding

Rebleeding typically occurs 3-5 days after initial injury.

Occurs in 5-30% of patients
Usually worse than initial bleed
Higher risk of complications
Risk factors: larger initial hyphema, use of aspirin/NSAIDs, poor compliance with activity restriction

Corneal Blood Staining

Blood penetrates into the cornea
Causes persistent vision impairment
May take months to years to clear
May be permanent
More likely with large hyphemas and elevated IOP

Other Complications

Optic atrophy: from prolonged elevated IOP
Angle recession: damage to drainage system causing later glaucoma
Synechiae: iris sticking to lens or cornea
Cataract: from trauma or chronic inflammation

Prognosis

Factors Affecting Outcome

Better Prognosis:

Small hyphema (Grade I)
No rebleeding
Normal IOP
No sickle cell disease
No other eye injuries
Good compliance with treatment

Worse Prognosis:

Large hyphema (Grade III-IV)
Rebleeding
Elevated IOP
Sickle cell disease
Associated eye injuries
Delayed treatment

Visual Outcomes

Most Grade I hyphemas resolve with good vision
Larger hyphemas and complications reduce chances
Associated injuries (retinal, optic nerve) affect outcome
Even after resolution, at risk for late glaucoma

Follow-Up

Acute Phase

Daily or every-other-day exams initially
Monitor IOP closely
Watch for rebleeding
Assess blood clearing

Long-Term

Long-term monitoring is essential after hyphema:

Risk of angle recession glaucoma (can develop years later)
Annual eye exams recommended
IOP monitoring
Gonioscopy to assess angle damage
May need lifelong surveillance

Prevention

Sports Eye Protection

Polycarbonate protective eyewear
Mandatory in high-risk sports (racquetball, paintball)
Reduces eye injury risk by 90%

General Safety

Wear safety glasses for hazardous activities
Childproof home environment
Supervise children with projectile toys

Frequently Asked Questions

How long does it take for the blood to clear?

Small hyphemas typically clear within a week. Larger ones may take several weeks. The blood is gradually absorbed by the body. During this time, activity restriction and close monitoring continue.

Will I have permanent vision damage?

Most patients with uncomplicated hyphema recover good vision. However, complications (elevated IOP, corneal staining, rebleeding) or associated injuries can cause permanent damage. Following treatment recommendations closely improves outcomes.

Why do I need bed rest?

Activity restriction reduces the risk of rebleeding, which typically causes a worse outcome than the initial injury. The blood vessel that bled is fragile during healing (especially days 3-5). Physical activity, bending, and straining can cause it to rebleed.

Can I take pain medicine?

Avoid aspirin and NSAIDs (ibuprofen, naproxen) as they increase bleeding risk. Acetaminophen (Tylenol) is usually safe. Your doctor may prescribe other pain medication if needed.

Why do I need sickle cell testing?

Sickle cell disease or trait significantly increases the risk of complications from hyphema. Treatment is modified in these patients. Testing is recommended for anyone at risk (African descent, Mediterranean, Middle Eastern, South Asian).

Will I be at risk for future eye problems?

Yes. Angle recession (damage to the drainage system) can cause glaucoma years after the injury. This is why long-term annual eye exams and IOP monitoring are recommended even after the hyphema has resolved.

References

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