|Year : 2014 | Volume
| Issue : 4 | Page : 128-131
Traumatic hyphema in Benin City, Nigeria
Odarosa M Uhumwangho, Onoriode C Umolo
Department of Ophthalmology, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||11-Dec-2014|
Odarosa M Uhumwangho
Department of Ophthalmology, University of Benin Teaching Hospital, P. M. B. 1111, Benin City
Source of Support: None, Conflict of Interest: None
Background: Hyphaema is a common sequalae following trauma. Th aim of this study was to determine the demographics, pattern, complications and visual outcome in patients managed with traumatic hyphema. Materials and Methods: A retrospective review of all cases of traumatic hyphema seen from July 1, 2008 to June 30, 2013. Data analyzed included biodata, duration of injury prior to presentation, grading of hyphema and activity during injury, visual acuity, intraocular pressure, associated injuries and complications. Results: A total of 45 eyes in 45 patients with traumatic hyphema were reviewed. The mean age of the patients was 27.3 ± 18.6 years with 44.4% occurring in the age group 0-20 years. The male:female ratio was 6.5:1. About 40.0% of patients presented within 24 h of the injury and 51.1% with Grade 1 hyphema. Injury occurred mostly during play and at work in 17.8% each. The initial visual acuity was worse than 6/60 in 82.0% but decreased to 60.0% following treatment while visual acuity of 6/18 or better increased from 6.7% at initial presentation to 31.1% following treatment. Lid and corneal injuries were the most common associated injuries in 20.0% each, while secondary glaucoma was the most common complication of hyphema in 22.2%. Conclusion: Traumatic hyphema is a common occurrence in children and young adults during play and at work. Early presentation, associated injuries, complications and management affects visual outcome.
Keywords: Traumatic hyphema, complications, prognosis
|How to cite this article:|
Uhumwangho OM, Umolo OC. Traumatic hyphema in Benin City, Nigeria. Sahel Med J 2014;17:128-31
| Introduction|| |
Hyphema is the presence of red blood cells in the anterior chamber (AC) of the eye.  It occurs commonly from blunt or penetrating ocular trauma. , It may also occur following intraocular surgery, tumors of the iris such as iris melanoma and juvenile xanthogranuloma and conditions causing iris neovascularization as in diabetes mellitus, sickle cell disease and keratouveitis. , Conditions which inhibit platelet or thrombin function such as leukemia, hemophilia or drugs such as ethanol, aspirin, and warfarin can result in hyphema. 
The management of hyphema involves medical, surgical and ancillary measures. Many factors determine the prognosis in the management of hyphema. These include the cause of hyphema, time of presentation, intervention, associated injuries and complications. ,, Its management is surrounded with a lot of controversy as to the best practices which could reduce the complications including secondary glaucoma, rebleed, corneal blood staining, uveitis, synechiae formation, cataract and vitreous hemorrhage. ,,,,, The aim of this study is to determine the demographics, pattern, complications and visual outcome in patients managed with hyphema.
| Materials and methods|| |
This is a retrospective study of all patients with hyphema admitted between July 1, 2008 and June 30, 2013 to the eye ward of the University of Benin Teaching Hospital, Benin City, Nigeria. Information on the patients seen within the stipulated period was obtained and analyzed using the GraphPad Instat Software, Inc. version V2.05a software program. Data collected included age, sex, occupation, cause of hyphema, activity at the time of hyphema, time of presentation and visual acuity on presentation, discharge and at follow-up. The grade of hyphema was according to the level of the AC filled with blood as determined by slit lamp biomicroscopy  grade 1: Hyphema filling less than one third of the AC; Grade 2: Hyphema fills one-third to one half of the AC; Grade 3: Hyphema fills greater than half of the AC, and Grade 4: Total hyphema with either red or black blood clots. The presence of a rebleed, intraocular pressure and complications associated with hyphema were documented. The standard operating procedure of the department in the management of hyphema during the study period included admission of all patients with traumatic hyphema, restriction of activities, patching of affected eyes, use of cycloplegics either guttae homatropine or atropine, steroid eye drops usually dexamethasone or betamethasone, intraocular pressure lowering drops using guttae timolol, brinzolamide, dorzolamide, brimonidine or oral medication with acetazolamide tablets after checking the genotype to rule out sickle cell disease. Paracentensis, AC washout or surgical evacuation of hyphema was performed in uncontrolled intraocular pressure, or Grade 4 hyphema to prevent corneal blood staining. The study was conducted in accordance with applicable ethical guidelines.
| Results|| |
A total of 45 eyes in 45 patients were seen during the study period. This comprised 39 males (86.7%) and 6 females (13.3%). [Table 1] shows the age and sex distribution of patients. The mean age was 27.3 ± 18.6 years (range 4-73 years) with 20 (44.4%) patients being ≤ 20 years of age. There were 24 (53.3%) right eyes and 21 (46.7%) left eyes involvement. Only 18 (40.0%) patients presented within 24 h of injury [Table 2]. Most of the patients 23 (51.1%) had Grade 1 hyphema while rebleed occurred in 6 (13.3%) patients. Surgical intervention (paracentensis, AC washout or clot expression) was performed in 8 (17.8%) patients. The mean duration of hospital stay was 13.5 ± 10.3; range (2-56 days) as presented in [Table 3].
|Table 1: Age and sex distribution in 45 patients with traumatic hyphema |
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|Table 3: Grade of hyphema, presence of rebleed, surgical intervention and duration of hospital stay |
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The most common activity at the time of injury were play and work related in 8 (17.8%) each, sports/leisure 7 (15.6%), assault/fight 6 (13.3%), corporal punishment and domestic injuries 4 (8.9%) each [Table 4]. Agents responsible for hyphema during play included rubber bands, missiles of stones and fruits from trees, sticks, catapult, writing materials and other play materials. Materials which caused injury at work were wood and sticks in farmers and timber haulage, iron rods in welders and mechanics and rope in a bike rider. Football and fireworks were responsible for injury during sports/leisure activities. Sticks, slaps, blows, bottles and gunshots caused injury during assault/fight. Canes and belts were the objects used by parents, older siblings or teachers during corporal punishment. Domestic causes include wine corks, metal gate and the boot of a car.
The initial visual acuity was worse than 6/60 in 36 (82.0%) and 6/18 or better in 3 (6.7%). The number of patients with a final visual acuity of 6/18 or better increased to 14 (31.1%) while those with visual acuity of less than 6/60 were 13 (60.0%). This is presented in [Table 5]. This improvement in visual acuity between initial presentation and final visual acuity was statistically significant (P < 0.001). There was also a statistically significant difference between the time of presentation and final visual acuity (P < 0.001) and between the grade of hyphema and final visual acuity (P < 0.001). However, there was no statistically significant difference between the time of presentation and grade of hyphema (P > 0.05). The associated ocular injuries and resulting complications arising is presented in [Table 6]. The most common associated ocular injury was lid abrasion/laceration and corneal laceration/ulcer in 9 (20.0%) patients each, while the most common resulting complication from hyphema was secondary glaucoma and rebleed in 10 (22.2%) and 6 (13.3%) patients respectively.
| Discussion|| |
Traumatic hyphema is not an uncommon sequalae from ocular injury. Males were more affected than females with a ratio of 6.5:1 which agrees with the findings of other studies. ,,,,,, In Eastern Nigeria, Onyekwe  found a male: female ratio of 3.5:1. Ashaye  from Western Nigeria reported a male: female ratio of 2.5:1 while Amoni  from Northern Nigeria found a male: female ratio of 3:1. The male dominance is likely due to the combination of factors including male involvement in trauma prone activities. A majority of the patients 44.4% were 20 years old or younger. This is lower than reports from similar studies in other parts of the country where 71.6%, 55.1%, and 75% from the West, East and North of Nigeria respectively belonged to this age group. ,, Previous studies have implicated corporal punishment as a major cause of ocular injuries in children and suggested the need to enforce alternative means of discipline to safeguard the ocular health of children who are still in their formative years to prevent avoidable morbidities and blindness. ,,,, Unsupervised play is also a common cause of ocular injury in this age group especially in the first decade of life. 
Early presentation of hyphema is associated with good prognosis. In this study, only 40.0% presented within 24 h from the time of injury which agrees with studies from other parts of the developing world with similar low figures ranging from 8% to 34.2% ,, In contrast, the developed countries have higher figures ranging from 84% to 100%. ,, This is a reflection of the health seeking behavior of the populace with prevalent practice of self-medication, as many patients in the developing nations visit patent medicine stores, native doctors and apply harmful traditional eye medications to the eye which further jeopardizes the outcome following injury. 
The most common presentation was Grade 1 hyphema (51.1%) and rebleed (13.3%). Other studies have Grade 4 as being the most common presentation. ,, In Kaduna, Northern Nigeria, Grade 4 hyphema and rebleed were present in 39.4% and 9.1% of patients, respectively.  Surgical intervention was done in 17.8%. This is usually done in patients with risk of corneal blood staining or persistently raised intraocular pressures. Patients who require surgical intervention in the treatment of hyphema usually have poorer overall results. , The mean duration of hospital stay was 13.5 days. Some studies show good outcomes with out-patient management of hyphema. , This is a feasible option in patients who are well motivated, adhere to instructions and do not default in follow-up clinic visits as it reduces the cost of hospital stay. However, out-patient management of hyphaema in the setting of a developing world is not advocated because of interplay of many factors such as poor awareness, access to health care facility with eye care, level of literacy and poor adherence.
Most of the injury occurred during play and work related activities. Educating children on use of safe objects at play is paramount. The injuries at work occurred mostly in artisans, farmers, mechanics, and welders. The use of protective eye devices in risk prone jobs should be enforced by government, trade unions and employers of labor. Injury from fireworks during leisure and road traffic accidents also caused eye injuries. There should be controlled use of fireworks during festive periods to prevent injuries. Road worthiness of vehicles should be ensured to reduce the rate of road traffic accident related eye injuries
The visual outcome showed some improvement from initial presentation to final follow-up. Prognosis is affected by factors such as time of presentation, grade of hyphema and associated ocular injury such as cornea and scleral laceration, vitreous hemorrhage and retinal complications. , Corneal laceration/ulcers was an associated injury in 20% of eyes in the current report. This can result in corneal opacity and corneal blindness which can further worsen the prognosis. Secondary glaucoma which can further compromise eyes with hyphema due to optic nerve head damage occurred in 22.2% of eyes.
| References|| |
Walton W, Von Hagen S, Grigorian R, Zarbin M. Management of traumatic hyphema. Surv Ophthalmol 2002;47:297-334.
Pearlman JA, Au Eong KG, Kuhn F, Pieramici DJ. Airbags and eye injuries: Epidemiology, spectrum of injury, and analysis of risk factors. Surv Ophthalmol 2001;46:234-42.
Lai JC, Fekrat S, Barrón Y, Goldberg MF. Traumatic hyphema in children: Risk factors for complications. Arch Ophthalmol 2001;119:64-70.
Amoni SS. Traumatic hyphaema in Kaduna, Nigeria. Br J Ophthalmol 1981;65:439-44.
Onyekwe LO. Factors affecting the visual outcome in hyphema management in Guinness Eye Center Onitsha. Niger J Clin Pract 2008;11:364-7.
Ashaye AO. Traumatic hyphaema: A report of 472 consecutive cases. BMC Ophthalmol 2008;8:24.
Rocha KM, Martins EN, Melo LA Jr, Moraes NS. Outpatient management of traumatic hyphema in children: Prospective evaluation. J AAPOS 2004;8:357-61.
Shiuey Y, Lucarelli MJ. Traumatic hyphema: Outcomes of outpatient management. Ophthalmology 1998;105:851-5.
Edwards WC, Layden WE. Traumatic hyphema. A report of 184 consecutive cases. Am J Ophthalmol 1973;75:110-6.
Behbehani AH, Abdelmoaty SM, Aljazaf A. Traumatic hyphema- Comparison between different treatment modalities. Saudi J Ophthalmol 2006;20:164-6.
Oluwakemi AB, Kayode A. Corporal punishment-related eye injury in Nigerian children. J Indian Assoc Pediatr Surg 2007;12:76-9.
Ayanniyi AA, Mahmoud OA, Olatunji FO, Ayanniyi RO. Pattern of ocular trauma among primary school pupils in Ilorin, Nigeria. Afr J Med Med Sci 2009;38:193-6.
Nwosu SN. Domestic ocular and adnexal injuries in Nigerians. West Afr J Med 1995;14:137-40.
Onyekwe LO. Spectrum of eye injuries in children in Guinness eye hospital. Nig J Surg Res 2001;3:126-32.
Abiose A. Eye injuries in Lagos. Nig Med J. 1995;5:105-7.
Oliver AJ, Patricia LH, Bradford JS. The spectrum and burden of ocular injury. Am J Ophthalmol 1998;300-5.
Darr JL, Passmore JW. Management of traumatic hyphema: A review of 109 cases. Am J Ophthalmol 1967;63:134-6.
Oksala A. Treatment of traumatic hyphema. Br J Ophthalmol 1967; 51: 315-20.
Ukponmwan CU, Momoh N. Incidence and complications of traditional eye medications in Nigeria in a teaching hospital. Middle East Afr J Ophthalmol 2010;17:315-9.
Jan S, Khan S, Mohammad S. Hyphaema due to blunt trauma. J Coll Physicians Surg Pak 2003;13:398-401.
Wilson FM. Traumatic hyphema. Pathogenesis and management. Ophthalmology 1980;87:910-9.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]