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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 may lead to permanent impairment of vision. Patients 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 CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2013), EMBASE (January 1980 to August 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 30 August 2013., Selection Criteria: Two 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 interventions versus other medical interventions 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 enrolment., Data Collection and Analysis: Two authors independently extracted the data for the primary and secondary outcomes. We entered and analyzed data using Review Manager 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as odds ratios and continuous outcomes as mean differences., Main Results: We included 20 randomized and seven quasi-randomized studies with 2643 participants in this review. Interventions included antifibrinolytic agents (oral and systemic 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. No intervention had a significant effect on visual acuity whether measured at two weeks or less after the trauma or at longer time periods. The number of days for the primary hyphema to resolve appeared to be longer with the use of aminocaproic acid compared with no use, but was not altered by any other intervention.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (odds ratio (OR) 0.25, 95% confidence interval (CI) 0.11 to 0.57), but a sensitivity analysis omitting studies not using an intention-to-treat (ITT) analysis reduced the strength of the evidence (OR 0.41, 95% CI 0.16 to 1.09). We obtained similar results for topical aminocaproic acid (OR 0.42, 95% CI 0.16 to 1.10). We found tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (OR 0.25, 95% CI 0.13 to 0.49), as did aminomethylbenzoic acid as reported in one study (OR 0.07, 95% CI 0.01 to 0.32). The evidence to support an associated reduction in the risk of complications from secondary hemorrhage (i.e. corneal bloodstaining, 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 difference in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The available evidence on usage of corticosteroids, cycloplegics, or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no difference in 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: Traumatic hyphema in the absence of other intraocular injuries uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to permanent impairment of vision, especially in patients with sickle cell trait/disease. We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review. Although evidence was limited, it appears that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients treated with aminocaproic acid take longer to clear.Other than the possible benefits of antifibrinolytic usage to reduce the rate of secondary hemorrhage, the decision to use corticosteroids, cycloplegics, or nondrug interventions (such as binocular patching, bed rest, or head elevation) should remain individualized because no solid scientific evidence supports a benefit. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.

A 34-year-old man was examined 4 hours after blunt ocular trauma with a stone. Visual acuity was hand motions in the right eye and 10/10 in the left eye. Slit-lamp examination after resorption of a hyphema revealed 180◦ superior iridodialysis and a total white intumescent cataract precluding visualization of the posterior capsule. Phacoemulsification was undertaken after repositioning the iris with microretractors. Intraoperatively, we discovered that the cen-tral portion of the posterior capsule presented a 4-mm oval opening with thick and fibrosed edges. The posterior chamber lens was safely implanted in the bag with no enlargement of the posterior capsule rupture. Postoperatively, VA improved only to 1/20 and fundus OCT revealed the presence of a 400-micron, oval-shaped macular hole that was successfully closed with sub-sequent vitrectomy and gas tamponade. Visual acuity stabilized at 5/10, D3, and the lens was stable without decentration after 36 months follow-up., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Purpose: To report the demographics and outcomes in children (<18 years of age) who developed hyphema from ocular trauma and were subsequently cared for at a tertiary medical center., Methods: The medical records of consecutive patients seen at Children's Hospital Colorado diagnosed with traumatic hyphema between September 1, 2003, and December 31, 2011, were retrospectively reviewed. The following data were recorded: patient age, parent/guardian-reported ethnicity, sex, injury location, visual acuity, and intraocular pressure (IOP) at presentation and follow-up., Results: A total of 138 cases of unilateral hyphema were included, with 88% occurring in boys (mean age, 10.1 years; range, 1-19). Over 90% of injuries occurred in the home setting, with the most common mechanisms of injury being general play, projectiles from guns, and sports injuries occurring during games or practice. Only 3 patients had visual acuity <20/40 at 1 month's follow-up, and no patient experienced a rebleeding event. Most of the 33 patients with elevated IOP were managed medically; 4 (12%) required surgery., Conclusions: The majority of children with traumatic hyphema in this patient cohort were injured in the home setting. Very few patients underwent surgery for ocular hypertension, but higher IOP at presentation was associated with the need for surgical intervention. Outpatient care with activity restriction and topical medications usually led to resolution of hyphema without serious complications or visual loss., (Copyright © 2013 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

To report a case of bilateral spontaneous hyphaema in a patient on warfarin sodium for atrial fibrillation and COPD. A case report and literature review. A 76-year-old man presented with bilateral spontaneous hyphaema. There was no anterior chamber pathology known to predispose for spontaneous bleeding except for a history of paroxysmal atrial fibrillation treated with a daily dose of 3 mg of warfarin sodium. In addition, he was also suffering from severe COPD and was on oxygen supplementation. This is a rare case of a bilateral spontaneous hyphaema. Although the patient was on warfarin sodium, his INR was only 2.6 at the onset of his symptoms. It may be possible that the combined action of anti-coagulant properties of warfarin sodium and hypoxic vasodilatation of iris vessels may be responsible for bilateral hyphaema in this case.

Importance: Pressure-induced stromal keratopathy is a rare kind of complication of laser in situ keratomileusis (LASIK) that may cause vision loss in affected eyes. Herein, we described the clinical features and treatment of 2 cases of pressure-induced stromal keratopathy due to traumatic hyphema in post-LASIK eyes., Observations: Two patients sought treatment for painful vision loss after blunt trauma on post-LASIK eyes. On examination, high intraocular pressure was found in the injured eyes. Hyphema was seen in the anterior chamber. High-resolution slitlamp biomicroscopy demonstrated interface hyperreflection, which resembled interface keratitis. However, an isolated pocket of fluid was clearly demonstrated at the level of the LASIK flap interface in the anterior segment optical coherence tomographic images. After topical corticosteroid and antiglaucoma medication, the hyphema and the hyperreflection in the cornea resolved in several days. The intraocular pressure and visual acuity returned to normal levels. Repeated anterior segment optical coherence tomographic examinations revealed completed resolution of the interface fluid., Conclusions and Relevance: To our knowledge, this is the first report of pressure-induced stromal keratopathy caused by traumatic hyphema. Anterior segment optical coherence tomography plays a unique role in revealing occult interface fluid in post-LASIK eyes, which may masquerade as interface keratitis during slitlamp examination.

Background: We aimed to evaluate the etiologic factors, complications, follow-up, and treatment outcomes in serious hyphema following blunt ocular trauma in childhood., Methods: The medical records of 136 patients diagnosed as grade 3 or 4 hyphema due to blunt ocular trauma between January 2006 and December 2011 were evaluated. Visual acuity (VA), complications, and medical and surgical treatments were analyzed. Factors affecting visual prognosis were compared in grade 3 and 4 hyphema cases., Results: The mean age of patients was 9.7±4 years. Etiologic factors for trauma were stone in 53 (39%), bead bullet in 25 (18.4%) and others in 58 (42.6%) patients. The most common complication of grade 3 and 4 hyphema was traumatic mydriasis (19.1%), followed by cataract (9.6%) and glaucoma (5.1%). Medical treatment was successful in 114 (83.8%) patients, and 22 (16.2%) patients underwent surgery. Mean initial and final VA of grade 4 patients were found to be significantly lower than those of grade 3 patients., Conclusion: In grade 3 and 4 hyphema due to blunt trauma, visual prognosis worsened in the presence of additional ocular pathologies. Considering the bad visual prognosis of severe hyphema patients, prompt treatment and close follow-up may prevent complications resulting in poor VA.

Unlabelled: We report a case of ischemic optic neuropathy arising from elevated intraocular pressure (IOP) masked by interface fluid in a post-laser in situ keratomileusis (LASIK) eye. A 51-year-old man, who had had LASIK 6 years prior to presentation, sustained blunt trauma to the left eye that resulted in a hyphema and ocular hypertension. Elevated IOP resulted in accumulation of fluid in the stromal bed-LASIK flap interface, leading to underestimation of IOP when measured centrally over the flap. After days of unrecognized ocular hypertension, ischemic optic neuropathy developed. To our knowledge, this is the first reported case of ischemic optic neuropathy resulting from underestimated IOP measurements in a post-LASIK patient. It highlights the inaccuracy of IOP measurements in post-LASIK eyes and a vision-threatening potential complication., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Importance: To our knowledge, this is the first study to describe the correlation of anterior chamber bleeding after laser peripheral iridotomy (LPI) and antiplatelet therapy., Objective: To determine the incidence and amount of anterior chamber bleeding after laser peripheral iridotomy in patients whose condition is suggestive of primary angle-closure glaucoma (PACS) who continued their antiplatelet or anticoagulant treatment before undergoing LPI compared with when they discontinued treatment., Design and Setting: A prospective controlled trial., Patients: Patients with suspected bilateral primary angle-closure and no other ocular disease who take antiplatelet or anticoagulant medications regularly (from January 2010-October 2011) were enrolled., Main Outcome and Measure: The incidence of anterior chamber bleeding with and without antiplatelet and anticoagulant therapy., Results: A total of 104 patients (208 eyes) participated in the study. Thirty-six eyes (34.6%) in the treated and untreated arms bled. The amount of bleeding did not differ significantly when the patient was on or off antiplatelet or anticoagulant treatment, nor did the immediate postprocedure mean intraocular pressure (P = .13). The type of antiplatelet or anticoagulant, total laser energy, age, sex, or color of irides were not risk factors for increased bleeding (P = .156 for all parameters)., Conclusions: No indication was noted for discontinuing these medications before a high-powered pulsed laser peripheral iridotomy.

Purposes: To describe a case of hemorrhagic Descemet membrane detachment following canaloplasty and to discuss its management using neodymium:yttrium-aluminum-garnet (Nd:YAG) laser Descemet membranotomy., Methods: Interventional case report., Results: A 71-year-old woman with chronic open-angle glaucoma developed a hemorrhagic Descemet detachment after combined phacoemulsification, intraocular lens insertion, and canaloplasty. The hematoma did not improve with initial expectant management. Two and a half weeks after surgery, the Nd:YAG laser was applied to create a break in the Descemet membrane in the region of the hematoma. The intracorneal blood quickly dissipated into the anterior chamber. Visual acuity improved to 20/20. The endothelial cell count was 2342 cells per square millimeter 4 years after the surgery. Pachymetry did not show any long-term alterations as a result of the Nd:YAG treatment., Conclusions: Hemorrhagic Descemet detachment is an uncommon complication after canaloplasty. Nd:YAG Descemet membranotomy is a successful means of clearing the hematoma and thus can prevent further complications, such as corneal blood staining.

Purpose: To assess risk factors for failure in canaloplasty., Methods:   Nonrandomized prospective study involving 51 eyes of 51 patients with medically uncontrolled primary open-angle glaucoma undergoing canaloplasty. Visual acuity, intraocular pressure (IOP) and slit-lamp examinations were performed before and after surgery at 1 and 7 days, and at 1 month and every 3 months thereafter. Factors like age, gender, preoperative IOP and microhyphema on day 1 were evaluated., Results:   The mean follow-up was 20.6 (SD 8.3) months. The mean preoperative IOP was 26.8 (SD 5.2) mmHg; the mean postoperative IOP was 8.4 (4.2) mmHg at day 1 and 12.7 (1.7) mmHg at month 24. Microhyphema was found in 40 patients (85.1%) on day 1 after surgery. The height of microhyphema was 1.8 mm ± 0.4 (SD) (range 1-2.5), and the time of resorption was 6.6 days ± 2.8 (SD) (range 3-14) on average. No recurrence of hyphema has been observed. IOP < 16 mmHg without medications depended significantly on the presence of microhyphema (hazard ratios, HR 0.03, 95% CI 0.01-0.25, p < 0.001), but not on age (HR 1.00, 95% CI 0.91-1.09, p = 0.32), preoperative IOP (HR 0.98, 95% CI 0.85-1.12, p = 0.80), cup-to-disc ratio (HR 0.15, 95% CI 0.00-20.01, p = 0.45) and gender (HR 0.24, 95% CI 0.05-1.12, p = 0.07). Factors like preoperative IOP, age, gender, cup-to-disc ratio were not associated with microhyphema. There were no significant differences between patients with versus without microhyphema in regard to age, preoperative IOP, morphological and functional glaucomatous damage, number of medications and postoperative day 1 IOP. However, patients with microhyphema had significantly fewer Nd:YAG goniopunctures after surgery than patients without microhyphema (p < 0.001)., Conclusion: Microhyphema the first postoperative day seems to be a significant positive prognostic indicator in uneventful canaloplasty in regard to IOP reduction, possibly representing a restored and patent physiologic aqueous outflow system., (© 2011 The Authors. Acta Ophthalmologica © 2011 Acta Ophthalmologica Scandinavica Foundation.)

Introduction: Diagnosis and in time treatment of traumatic hyphema could prevent the consequent complications such as, intraocular pressure, blood deposition in the cornea, cataract, the optic nerve damage, and reduction of visual acuity, etc. The aim of this study is identifying the prevalence of the traumatic hyphema incidence in the patients referring to the University Hospital of Boo-Ali-Sina in the city of Sari (Northern Iran) in 2009 -2010., Method: In this descriptive cross-sectional study, 28 medical records related to traumatic hyphema were investigated. A checklist was designed to extract the data., Results: The most frequency of traumatic hyphema was related to male gender 22 (78/6%), 9 (32.1%) cases age 5-14 years, student 12 (42.9%)cases, 14(50%) urban, 10 (35.7%) cases length of stay was 3 days. The traumatic hyphema was most common in summer 11 (39.3%) cases. The majority 15 (53.6%) of subjects were unilateral (left eye). The mode of the trauma was contact with blunt object in 18 (64.2%) subjects. Protocol of treatment in most subjects 23 (82%) was medication and cornea operation in 2 (7.1%) cases. The highest frequency of the time period between the incidence of injury and referring to the hospital in less than 1 hour was reported in 10 (35.7%)., Conclusion: In the present study, the traumatic hyphema was observed more in male, especially in the young and adolescent and in the students and workers. Therefore the issue of prevention of ocular trauma and instruction about the eye protection is very important.

Intracameral injection of tissue plasminogen activator has been suggested as a means of hastening the clearance of blood from the anterior chamber and reducing the risk of synechia and fibrotic membrane formation in horses with hyphaema. The following report describes a case of ocular trauma in which intracameral injection of tenecteplase (TNK), a new-generation plasminogen activator, resulted in rapid resolution of hyphaema and successful outcome. However, a large dose (1 mg) was administered and may have been associated with retinopathy and keratopathy. TNK may be an effective treatment for equine hyphaema and further controlled clinical or experimental studies are required to determine its efficacy and safety profiles., (© 2012 The Authors. Australian Veterinary Journal © 2012 Australian Veterinary Association.)

Background: Hyphema is a complication that can occur after glaucoma filtering surgery. Biomicroscopic examination of the anterior segment is commonly used to diagnose it and gonioscopy may provide a useful support to find the source of the haemorrhage. Unfortunately, when the blood hides the structure of the anterior segment the gonioscopic examination fails. In this case we performed ultrabiomiscroscopy with 50-80 MHz probes to overcome the limits of gonioscopy. The use of this technique to study the anterior segment of the eye has previously been reported in literature, but we illustrates its importance for performing a correct diagnosis in a specific case of hyphema., Case Presentation: We report a case of a sixty-year-old caucasian male with recurrent hyphema in the left eye. The episodes of hyphema were four in two years and the patient came to the hospital for the first time in the last occasion. The past episodes were managed with topical corticosteroids and mydriatic drops. He referred surgical trabeculectomy in both eyes 5 years before the first symptoms and no specific eye trauma before the first episode. The examination of the anterior segment revealed a 2 mm hyphema in the left eye due to blood leakage through the superior iridectomy. Gonioscopy could not identify the source of the haemorrhage. B-scan ultrasound and ultrabiomiscroscopy, with 50-80 MHz probes, were performed. Ultrabiomiscroscopy, mainly with the probe of 80 MHz, provided images of high resolution of the structures of the anterior segment and it allowed the visualization of an abnormal vessel at the inner margin of the trabeculectomy opening, probably responsible of the recurrent hyphema., Conclusion: Ultrabiomicroscopy proved to be a useful diagnostic technique for identifying the cause of the recurrent hyphema when other examination techniques are not applicable.

Purpose: To describe patients who have experienced delayed-onset hyphema after ab interno trabeculotomy surgery with the Trabectome (Neomedix Corp) for open-angle glaucoma., Design: Retrospective case series., Methods: study population: Patients at Mayo Clinic, Rochester, Minnesota, who underwent Trabectome surgery between September 1, 2006, and December 31, 2010, and who had symptomatic hyphema at least 2 months after surgery. observation procedure: Patients with blurred vision at least 2 months after Trabectome surgery were examined for the presence of hyphema using a slit lamp and gonioscopy. main outcome measures: Proportion of patients experiencing delayed-onset symptomatic hyphema after Trabectome surgery. Associated factors and clinical course for these patients., Results: Of 262 cases of Trabectome surgery, there were 12 cases of delayed-onset symptomatic hyphema (4.6%). The average age was 74.3 years (range, 66 to 82 years). Median time to onset of hyphema was 8.6 months (range, 2 to 31 months) after surgery. Symptom onset commonly occurred on awakening. The most common characteristic was maintaining a sleep position on the surgical side. Most hyphemas resolved within 1 to 2 weeks, except in 1 patient, who required trabeculectomy for a refractory intraocular pressure spike., Conclusions: This is a series of patients with symptomatic delayed-onset hyphema after Trabectome surgery in the absence of further surgeries or trauma. Likely mechanisms are exertion-related increase in episcleral venous pressure or ocular compression from sleeping on the surgical side, followed by sudden decompression and blood reflux. Symptomatic patients should identify and avoid associated triggers because delayed-onset hyphema may be associated with intermittent intraocular pressure spikes that may require medical or surgical treatment., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To present a unique case of a 65-year-old man using warfarin who presented with acute unilateral loss of vision due to hemorrhagic Descemet membrane detachment (DMD) with pupillary block and elevated intraocular pressure and its subsequent treatment and challenges., Method: Case report., Results: Clinical examination showed a visual acuity of finger counting, central DMD with near contact to the iris and premembrane hemorrhage, an intraocular pressure (IOP) of 19 mmHg, and normal pupillary reaction. An International Normalized Ratio (INR) of 4.9 was treated with dose reduction and vitamin K. Twelve hours later the patient re-presented with an acute increase in pain and an IOP of 78 mmHg with pupillary block and iris bombé. YAG-laser membranotomy, anterior chamber paracentesis, and maximal topical and systemic therapy were unsuccessful in reducing the IOP. Surgical management, including irrigation and aspiration of blood, led to a normalization of the IOP. Descemet stripping automated endothelial keratoplasty (DSAEK) resulted in a visual acuity of 0.3. Deep stromal/pre-Descemet membrane neovascularization was found bilaterally, suspicious for a previous interstitial keratitis., Conclusions: The previously unreported complication of pupillary block following a pre-Descemet membrane hemorrhage was treated successfully for the first reported time, in a 2-step DSAEK. This indicates that DSAEK could be considered as a treatment option for DMD, especially in traumatic circumstances.

Ocular traumas represent a major public health problem with poorly understood ramifications at both the individual and community levels. Any of the ocular structures can be damaged in the case of closed globe injury. These lesions, often multiple, may appear immediately or in a delayed fashion. Classifications have been developed recently in order to better inform the patient of the visual prognosis. However, significant efforts are still needed, on the one hand, to assess and develop new therapies, and on the other hand, to implement effective policies to prevent ocular trauma., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Background: Blunt force trauma can affect all structures in the eye, frequently causing complications such as hyphema or microhyphema. A hyphema is defined as bleeding in the anterior chamber that layers and forms a visible clot. A microhyphema occurs when the red blood cells are suspended in the anterior chamber, and do not form a layered clot. Microhyphema is a rarely reported, visually significant complication. Ocular trauma is the second most common cause of visual impairment, and appropriate management must be executed swiftly and efficiently to maximize a patient's visual potential;, Case Report: A 21-year-old Indian male presented after ocular contusion to the right eye. His visual acuity was reduced at initial presentation. Pertinent clinical findings included red blood cells in the anterior chamber and ecchymosis of the orbital adnexa, with associated conjunctival injection. Subsequently, the patient developed commotio retinae;, Conclusion: It is important for clinicians to take a detailed case history of the event, perform a thorough ocular exam, select proper treatment/therapy, monitor the patient closely, and make appropriate referrals as needed. This case report discusses the clinical findings, treatment, and management of 1 patient with an ocular contusion resulting in microhyphema and commotio retinae., (American Optometric Association.)

Purpose: To present ultrasound biomicroscopic (UBM) findings and their clinical correlations in people with optically hazy media after injury at the Persian Wednesday Eve fireworks festival., Methods: Ultrasound biomicroscopy was performed on a series of 32 eyes with severe closed-globe injuries by P40 ultrasound biomicroscope., Results: The median age of the participants was 19 years, and 81.3% were male. All but one had gross hyphema. Seventy-five percent had an extension of the injury (at least) to Birmingham Eye Trauma Terminology zone II. Ultrasound biomicroscopy detected 3 more iridodialyses and 10 more cyclodialyses in addition to the respective 5 and 3 that were diagnosed clinically. Ten cases of angle recession were observed, and 5 were suggestive of subluxation of the crystalline lens. Two cases were suspected for anterior segment intraocular foreign body on clinical examination, but UBM and computed tomography scanning together ruled out such a diagnosis., Conclusions: Our study showed the value of UBM in the assessment of severely contused eyes and hyphema. It made possible evaluation for dialyses and recessions at presentation. Ultrasound biomicroscopy illustrated diverse subclinical disruptions in clinically invisible anterior segment structures.

To report a case of microtrauma-induced recurrent hyphema and secondary glaucoma associated with voluntary chronic acetylsalicylic acid (ASA) use. A 43-year-old male developed advanced glaucoma in his right eye after a two-month followup period of recurrent microhyphema, which had been induced by strong eye-rubbing. In spite of topical and systemic antiglaucoma medication, as well as topical corticosteroid and cycloplegic drugs and bed rest under hospitalization, the hyphema and glaucoma were not controlled. His medical history revealed that he had been using ASA for 2 years in order to prevent heart attacks. We asked the patient to stop ASA intake and the hyphema cleared considerably on the third day after discontinuation of the drug. One week after stopping ASA, trabeculectomy with mitomycin C was performed without any complications. Glaucoma and recurrent hyphema were controlled after surgery without any medical treatment. Chronic ASA intake may cause recurrent hyphema and secondary glaucoma even after a microtrauma. Medical histories of patients must always be taken, especially in cases of prolonged recurrent hyphema.

Purpose: To report ocular injuries caused by airsoft guns in children., Methods: A retrospective chart review of pediatric patients who sustained ocular injuries related to airsoft guns between November 2005 and December 2007. Place of trauma, presenting symptoms and signs, surgical interventions performed, and final visual outcome were reviewed., Results: Thirty-two patients with a mean age of 8.8 ± 4.0 years (range: 1.5 to 18 years) were examined; 28 were boys (87.5%). Presenting visual acuity ranged from hand motions to 20/20 and could not be assessed in 2 patients. Hyphema was a common finding that was present in 24 cases, corneal abrasions were present in 10 cases, and raised intraocular pressure was present in 7 cases. Seven patients presented with traumatic cataract, and two had iridodialysis. Immediate surgical intervention was performed in 7 patients and 7 patients were scheduled for elective surgery. The patients presented after an average of 1.9 ± 1.9 days (range: 4 hours to 6 days) after the injury. Average follow-up was 18 days (range: 7 days to 5 months). Final visual acuity was 20/200 or worse in 5 patients, 20/40 or better in 23 patients, and could not be assessed in 2 cases., Conclusion: Airsoft guns can cause a variety of serious injuries, sometimes necessitating operative intervention. The long-term morbidity from some of these injuries is significant. Airsoft guns are capable of inflicting serious and permanent ocular damage., (Copyright 2012, SLACK Incorporated.)

Background: To describe the technique for the removal of bulky fibrin in persistent traumatic full hyphema by using anterior chamber maintainer (ACM)., Methods: The ACM was used to reform and maintain the anterior chamber, and to flush out the clotted blood. The ACM cannula was inserted at the 6 o'clock position, and then a 2-mm-width contra lateral limbal incision was made. Slight pressure applied at the posterior lip of the incision facilitated the evacuation of the clot from the anterior chamber. Visible adherence of the clot was separated using the Sinskey hook, and firm fibrosis between fibrin and intraocular structure was cut by Vannas scissor., Results: All liquified blood was removed through corneal incision. Any clot caught at the incision was removed by cutting the clot into smaller fragments with a Vannas scissor., Conclusion: ACM is a safer and affordable alternative compared to Simcoe's cannula or vitrectomy in the removal of persistent traumatic hyphema.

Aims: This study aimed to evaluate the efficacy of Gold Micro Shunt (GMS) for suprachoroidal drainage in patients with refractory glaucoma., Methods: This is a prospective uncontrolled case series study. Fifty-five eyes of 55 patients were included. Study eyes underwent GMS implantation in the supraciliary space. Follow-up visits were performed on day 1, week 1 and months 1, 3, 6, 12 and 24; patients underwent slit-lamp examination, Goldmann applanation tonometry, ultrasound biomicroscopy and gonioscopy., Results: Before inclusion, the eyes underwent an average (± SD) of 1.9 ± 0.7 (range 1-5) previous glaucoma surgery procedures. Forty eyes were pseudophakic, 12 were phakic and 3 were aphakic. The mean baseline intraocular pressure was 30.8 ± 8.8 mm Hg (range 22-58 mm Hg) despite maximal medical treatment. After 2 years of follow-up, qualified success was achieved in 37 eyes (67.3%) and complete success was achieved in 3 eyes (5.5%). In success group patients, mean intraocular pressure decreased from 27.6 ± 6.9 at baseline to 13.7 ± 2.98 mm Hg after 2 years of follow-up; the mean (± SD) number of medications was 1.4 ± 0.7 in the postoperative phase, compared with a value of 2.5 ± 0.9 in the preoperative phase. Mild side effects occurred in 21 patients, with mild or moderate postoperative hyphema being the most frequent one. Development of a thin membrane, obstructing the anterior holes, was the most important factor affecting the efficacy of this device; it was found to be present in 12 patients from the failure group (66.7% of failures)., Conclusion: GMS achieved qualified success in about 67.3% of eyes with uncontrolled refractory glaucoma with a low rate of complications.

Purpose: Cavernous hemangioma of the iris is rarely seen,which can be presented with spontaneous hyphema., Methods: In this report,we described a case of an iris cavernous hemangioma treated surgically,and the histopathological findings were also presented., Results: Slitlamp biomicroscopy showed a lobulated, reddish-blue temporal iris mass. Anterior segment OCT presented a circumscribed mass of iris stroma at the papillary margin. Histopathologic examination revealed a benign tumor composed of large blood-filled vessels., Conclusion: The present case highlights the features of iris cavernous henagioma and demonstrates the histopathological findings.

The authors report a case of a Descemet stripping automated endothelial keratoplasty that was complicated by intraoperative bleeding from the iridotomy site. Slit-lamp examination on postoperative day 1 revealed significant amount of retained blood at the donor-recipient interface and a best-corrected visual acuity (BCVA) of 20/400. The patient was managed with periodic observation and a topical fluoroquinolone and 1% prednisolone. By postoperative month 8, the interface had cleared, and the BCVA improved to 20/50. The patient remained with a clear cornea and stable BCVA of 20/50 at her most recent 1-year postoperative follow-up examination. Performing an intraoperative peripheral iridotomy to reduce the risk of air-associated pupillary block introduces the risk of its inherent complications, including intraoperative bleeding, retained blood cells at the interface, and delayed visual recovery. In this case, periodic observation and conservative management with topical steroids resulted in the resolution of the interface debris, associated keratitis, and improved postoperative visual acuity.

This is a report a case of presumed scleral perforation during globe retropulsion as part of the Guyton exaggerated traction test in a patient with a history of bilateral keratoconus and scleral thinning. Perforation was indicated by the sudden occurrence of hyphema and globe softening. Postoperatively, the hyphema resolved, the intraocular pressure normalized, and the patient regained preoperative visual acuity., (Copyright © 2011 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Objective: An attempt has been made to evaluate transient anterior chamber haemorrhage after canaloplasty., Method: In the period from November 2008 to October 2009 a total of 21 eyes in 17 patients underwent canaloplasty for primary open angle glaucoma in our clinic. At the end of surgery all eyes left the surgical table with an intraocular pressure (IOP) of 5 - 10 mmHg and a deep anterior chamber without any bleeding., Results: The IOP on day 1 after surgery was 9.6 mmHg in average. By that time 15 of 21 eyes showed anterior chamber haemorrhage with a hyphaema between 0.5 - 2 mm in height. Eyes without hyphaema showed an IOP of > 15 mmHg at the same time. In no case was there further haemorrhage, the blood was absorbed in all cases within a maximum of 1 week without further complications., Conclusion: In contrast to trabeculectomy, where the natural anterior chamber water outflow is by-passed via an artificial fistula, canaloplasty attempts to re-establish the physiological anterior chamber water draining system by means of a 360 degree viscocanalostomy and a thread mediated dilation of Schlemm's canal and its collector channels. If the anterior chamber pressure temporarily lowers the level of the venous capillary pressure, it is consistent with a patent piping system when a reverse flow with blood reflux into the anterior chamber can be observed as long as a minimal physiological pressure gradient from the anterior chamber in the direction of channel Schlemm's canal has been restored. Thus, in the authors opinion, anterior chamber haemorrhage shows the desired consistency of the water draining system and should therefore logically be expected after each successful operation in all cases where hypotony in the postoperative period occurs., (© Georg Thieme Verlag KG Stuttgart · New York.)

In the United States, it is estimated that 3% of all emergency room visits are the result of eye injury, with many seen in combination with other orbital injuries. These often result from motor vehicle accidents and sports-related injuries. Clinical ophthalmologic examination is the key to rapid and accurate diagnosis of most ocular injuries. Imaging, in combination with the ophthalmologic examination, can be a powerful tool in the evaluation of traumatic injury to the globe. We review the roles of computed tomography, magnetic resonance imaging, and ultrasound in the evaluation of these patients and illustrate common and uncommon traumatic ocular pathology., (Copyright © 2011 Elsevier Inc. All rights reserved.)

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 may lead to permanent impairment of vision. Patients 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: The objective of this review was to assess the effectiveness of various medical interventions in the management of traumatic hyphema., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2010, Issue 6), MEDLINE (January 1950 to June 2010), EMBASE (January 1980 to June 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (http://clinicaltrials.gov). We searched the reference lists of identified trial reports to find additional trials. We also searched the ISI Web of Science Social Sciences Citation Index (SSCI) to find studies that cited the identified trials. There were no language or date restrictions in the search for trials. The electronic databases were last searched on 25 June 2010., Selection Criteria: Two 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 interventions to other medical interventions or control groups for the treatment of traumatic hyphema following closed globe trauma. There were 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 authors independently extracted the data for the primary and secondary outcomes. We entered and analyzed data using Review Manager (RevMan) 5. We performed meta-analyses using a fixed-effect model and reported dichotomous outcomes as odds ratios and continuous outcomes as mean differences., Main Results: Nineteen randomized and seven quasi-randomized studies with 2,560 participants were included in this review. Interventions included antifibrinolytic agents (oral and systemic aminocaproic acid, tranexamic acid, and aminomethylbenzoic acid), corticosteroids (systemic and topical), cycloplegics, miotics, aspirin, conjugated estrogens, monocular versus bilateral patching, elevation of the head, and bed rest. No intervention had a significant effect on visual acuity whether measured at two weeks or less after the trauma or at longer time periods. The number of days for the primary hyphema to resolve appeared to be longer with the use of aminocaproic acid compared to no use, but was not altered by any other intervention.Systemic aminocaproic acid reduced the rate of recurrent hemorrhage (odds ratio (OR) 0.25, 95% confidence interval (CI) 0.11 to 0.5), but a sensitivity analysis omitting studies not using an intention-to-treat (ITT) analysis reduced the strength of the evidence (OR 0.41, 95% CI 0.16 to 1.09). We obtained similar results for topical aminocaproic acid (OR 0.42, 95% CI 0.16 to 1.10). We found tranexamic acid had a significant effect in reducing the rate of secondary hemorrhage (OR 0.25, 95% CI 0.13 to 0.49), as did aminomethylbenzoic acid as reported in a single study (OR 0.07, 95% CI 0.01 to 0.32). 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 compares with placebo. We found no difference in the number of adverse events with the use of systemic versus topical aminocaproic acid or with standard versus lower drug dose. The available evidence on usage of corticosteroids, cycloplegics or aspirin in traumatic hyphema was limited due to the small numbers of participants and events in the trials.We found no difference in effect between a single versus binocular patch nor ambulation versus complete bed rest on the risk of secondary hemorrhage or time to rebleed., Authors' Conclusions: Traumatic hyphema in the absence of other intraocular injuries, uncommonly leads to permanent loss of vision. Complications resulting from secondary hemorrhage could lead to permanent impairment of vision, especially in patients with sickle cell trait/disease. We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review. Although evidence is limited, it appears that patients with traumatic hyphema who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients on aminocaproic acid take longer to clear.Other than the possible benefits of antifibrinolytic usage to reduce the rate of secondary hemorrhage, the decision to use corticosteroids, cycloplegics, or non-drug interventions (such as binocular patching, bed rest, or head elevation) should remain individualized because no solid scientific evidence supports a benefit. As these multiple interventions are rarely used in isolation, further research to assess the additive effect of these interventions might be of value.

We present a case dealing with an uncommon presentation of retinoblastoma. An 4-year-old boy presented to the ophthalmic department for a red painful eye following trauma. The examination showed decreased visual acuity, total hyphema and ocular hypertony. Ocular ultrasonography revealed an intraocular process. CT-scan of the orbit was consistent with a retinoblastoma. Treatment consisted of an enucleation and chemotherapy. This paper stresses the fact that presentation of retinoblastoma is not stereotypic. Every effort should be made to exclude a tumoral intraocular process in all cases of hyphema, even in cases of well documented ocular trauma.

The authors present in detail (symptoms, signs, predisposing factors, complications, treatment) one of the most common signs seen in the eyeball contusion--traumatic hiphema. There are presented concepts for proper treatment of hiphema with secondary glaucoma and for relapsing hiphema.

Ocular snake-bite injuries are quite rare away from natural habitats. However, when exotic animals are kept in captivity, the injuries sustained and their management can pose challenges when they present to their local eye department. This report describes an atypical eye injury inflicted by a python and its successful management involving surgical, laser and medical interventions. The case highlights the possible pitfalls resulting from the unusual mechanism of injury and the steps to avoid them. The article goes on to discuss the background of the injuries that can be caused by venomous and non-venomous snakes.

A 60-year-old diabetic patient transferred to our retina clinic for a regular follow-up for diabetic retinopathy. He had uneventful cataract surgery at the time of pars plana vitrectomy in the right eye due to diabetic retinopathy at a private ophthalmologic hospital. Six months after the surgery, neovascular glaucoma with hyphema developed in the right eye and an Ahmed valve was implanted at our hospital. Ten months after cataract surgery, we found opacification of the intraocular lens (IOL) which was causing significant visual disturbance. At the time, the best corrected visual acuity (BCVA) in the right eye was hand motion. The IOL was explanted 45 months after the operation. Five months after explantation, the BCVA was 0.06. Unfortunately, pathologic analysis was not performed. Patient-related factors such as an anterior chamber reaction caused by hyphema might have been responsible for the opacification. To our knowledge, there are no previous reports of opacification of the Akreos Adapt IOL.

Purpose: To evaluate anterior segment complication rates in eyes treated for prethreshold versus threshold retinopathy of prematurity (ROP) and look for potential risk factors., Design: Retrospective, observational case series study., Methods: All patients treated with diode laser for ROP between 1995 and 2007 were identified. A total of 259 eyes of 184 patients were studied, 120 eyes in the pretheshold group and 139 eyes in the threshold group. We compare baseline characteristics, treatment parameters, ocular complications, and structural outcomes after treatment. The main outcome measured was anterior segment complication rates in eyes treated for prethreshold versus threshold ROP and we looked for potential risk factors., Results: Thirteen of 120 eyes treated at prethreshold had anterior segment complications versus 0 of 139 treated at threshold (P < .01). All eyes developed post-laser hyphema, 3 with elevated intraocular pressure. Three eyes developed cataract (2 requiring cataract extraction); 1 required treatment for band keratopathy. The mean postmenstrual age at treatment was significantly different between the prethreshold and threshold groups (36.6 vs 37.9 weeks, P = .03); eyes with anterior segment complications were treated at mean postmenstrual age of 35.7 weeks. No difference was found based on gestationtal age at birth, birth weight, zone, stage, or number of laser spots for eyes with anterior segment complications. Most anterior segment complications (77%) resolved without long-term sequelae., Conclusions: Younger postmenstrual age at laser treatment may be related to an increased risk of anterior segment complications, which should be recognized and managed appropriately., (2010 Elsevier Inc. All rights reserved.)

We report the first case of iris vascular tuft (Cobb's tuft) causing recurrent spontaneous hyphema and raised intraocular pressure that underwent laser photocoagulation (LaP). For the first time, we report fluorescein angiogram guided LaP of the lesion and feeder vessels and 1 year angiographic follow up. We also review indications and outcomes of LaP of iris vascular tufts in the literature.

The stingball is a "maximum effect device" delivering up to four stimuli for psychological and physiological effect, including rubber pellets, light, sound, and an optional chemical agent. The purpose of this case report is to describe the injury patterns of a less-lethal weapon that has been in use for over 20 years. Although the stingball has been available for many years, there is very little experience with it in the medical community. We describe the case of an inmate at Los Angeles county jail brought to LAC+USC Emergency Department after sustaining injuries from the deployment of a stingball to break up a jail riot., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Klippel-Trénaunay-Weber syndrome is characterized by the triad of capillary malformations (usually port-wine stains), varicose veins or venous malformations of unusual distribution, and soft-tissue or bony hypertrophy of an extremity. The syndrome can be diagnosed on the basis of 2 of these 3 features. In the atypical form of the syndrome, capillary malformations may be absent. Recognition is possible during infancy or early childhood, and evaluation and treatment is important to minimize morbidity. We describe the case of an 11-year-old girl who presented with hyphema after a Valsalva maneuver and was found to have persistent fetal vasculature in the affected eye. She had systemic features of Klippel-Trénaunay-Weber syndrome. Magnetic resonance imaging, magnetic resonance angiography, and magnetic resonance venography scans of the brain and orbits were normal. Magnetic resonance imaging scan of the left hypertrophied lower limb revealed venous malformations leading to soft-tissue hypertrophy. To our knowledge, this is the first case of persistent fetal vasculature and hyphema in a patient with Klippel-Trénaunay-Weber syndrome., (Copyright 2010 American Association for Pediatric Ophthalmology and Strabismus. Published by Mosby, Inc. All rights reserved.)

Purpose: To present the preliminary results of our study comparing the outcomes of trabeculectomy with or without OloGen implant in patients requiring glaucoma surgery for uncontrolled intraocular pressure (IOP)., Methods: Forty eyes of 40 patients were assigned randomly to undergo trabeculectomy either with OloGen implant (study group) or without implant (control group). Preoperative data included age, gender, type of glaucoma, IOP and number of preoperative glaucoma medications. Postoperative IOP, number of postoperative glaucoma medications and postoperative complications were recorded. Each patient was followed up for at least 6 months., Results: There were no significant differences between the groups in terms of age, gender, type of glaucoma, preoperative IOP and number of antiglaucoma medications. Mean IOPs for both groups were significantly lower than preoperative levels at all intervals (P < 0.05) The number of glaucoma medications used dropped from a preoperative mean of 3.5 +/- 0.7 to a 6-month postoperative mean of 0.3 +/- 0.7 (P < 0.001) in the study group and from 3.7 +/- 0.4 to 0.5 +/- 1.1 (P < 0.001) in the control group. No statistically significant differences between the two groups were observed in terms of postoperative complications., Conclusion: In this pilot study it appears that trabeculectomy with OloGen does not seem to offer any significant advantages compared with trabeculectomy alone. Additionally, even though there were no statistical differences between the two groups as far as complications were concerned, one eye from the study group developed endophthalmitis 10 days after surgery and two eyes presented with positive Seidel test and flat anterior chamber and required additional suturing. Studies with larger numbers of patients and longer follow-ups are required to confirm these findings and to examine the safety and long-term outcomes of trabeculectomy with OloGen.

Purpose: To study the intraocular pressure (IOP)-reducing effect of deep sclerectomy on normal-tension glaucoma (NTG) patients., Methods: We retrospectively analysed 21 eyes of 18 consecutive NTG patients who had undergone deep sclerectomy with mitomycin-C and a collagen implant., Results: Median (range) preoperative IOP was 15.1 mmHg (9.3-20.8) and median follow-up time 13 months (12-18). At the 1-year follow-up visit, median IOP was significantly (P < 0.001) reduced to 10.5 mmHg (4-15) with median IOP reduction from preoperative values of 37% (12-78). Laser goniopuncture was performed in 10 eyes (48%) 1-16 months postoperatively. After 13 months' follow-up, a complete success at 20%, 25% and 30% IOP reduction levels was achieved in 67%, 62% and 52% of eyes, respectively. Few complications were encountered, but these included reduced visual acuity, problems with conjunctiva, microperforation, hyphaema, Dellen formation and encapsulated bleb. We encountered no complications related to postoperative hypotony., Conclusion: Deep sclerectomy with a collagen implant and mitomycin-C was a safe and effective method for reducing IOP in NTG patients during 1-year follow-up.

Purpose: The purpose of this study was to report a case of nondisplacement of an endothelial keratoplasty (EK) lenticule after traumatic rupture of the globe., Methods: The authors conducted a review of the clinical course of a 35-year-old woman who sustained a traumatic rupture of the globe 4 months after Descemet stripping endothelial keratoplasty., Results: The rupture did not involve the 4-month-old temporal scleral tunnel wound used for the EK. The lenticule was attached despite the injury and remained so in the postoperative course., Conclusions: Blunt trauma after endothelial keratoplasty can result in the disruption of the operative wound and lenticule dislocation. However, in our case, the rupture site did not involve the surgical wound, and the lenticule remained attached throughout the trauma, the surgical repair of the ruptured globe, and the postinjury course. This case illustrates the potential strength of EK wounds and the strength of adhesion of the transplanted lenticule and poses unanswered questions about the process of wound healing and attachment of donor lenticules in EK cases.