SGEM#18: Eye of the Tiger
Date: 6 January 2013
Title: Eye of the Tiger
Case Scenario: 18yo male who was “doing nothing” when someone jumped him and punched him in the face. He has a hyphema in his left eye. His visual acuity is 20/20 OU and has no other injuries.
Background on Traumatic Hyphema: Hyphemas are defined as blood in the anterior chamber (between the cornea and iris). It often results from a blow/direct trauma to the eye. Young men suffer from this condition in a 3:1 ratio compared with women. Sports injuries were responsible for 60% of cases. Traumatic hyphemas rarely result in permanent vision loss and resolve without any treatment. Antifibrinolytics have been tried either orally or topically applied to try and prevent vision loss.
Question: What should be done for a traumatic hyphema in the Emergency Department?
Reference: Gharaibeh A. et al. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD005431. DOI:10.1002/14651858.CD005431.pub2.
- Population: 19 randomized and 7 quasirandomized studies (n=2,560) with traumatic hyphemas.
- Intervention: Both Medical and NonMedical
- Control: Placebo, standard care or observation
- Outcome: Primary: VA time of resolution. Secondary outcome: risk of and time to rebleed, risk of corneal bloodstaining, risk of peripheral anterior synechia, risk of pathological increase in IOP and risk of optic atrophy development.
- Primary: No change in primary end point – Time to best VA or Final VA following hyphema?
- Secondary: Antifibrinolytics reduce the risk of secondary bleeding, hyphema took longer to resolve but VA in the end was not different.
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.”
Canadian Content: This comes from a Canadian Beer ad from a few years ago. It is something to visually explain the pulling of the jersey over the other guys head before a fight…very hockey night in Canada-ish. Just click on the picture and enjoy.
BEEM Commentary: Trauma to the eye can lead to blood in the anterior chamber. The hyphema is typically a self-limiting condition and is rare to cause permanent vision loss. Many medical treatments have been tried to improve visual outcome and speed up resolution. The most common topical or oral medical is the antifibrinolytics (tranexamic acid or aminocaproic acid) despite being controversial. Many other modalities have also been tried with variable effect (steroids, cycloplegics and ASA). Non-medical treatment has also been tried. These included patching of the eye, bed rest, elevation of the head, and admission to hospital. This Cochrane review is typical of systematic reviews coming out of this collaborative. They searched lots and lots of papers, found few to include and the quality was limited. No intervention made a positive impact on the primary outcome. Despite the negative results they were able to produce a 145 page review that said nothing impacts the primary outcome and highlight that the secondary outcome of less re-bleeds took place on antibibrinolytics but were poorly tolerated.
BEEM Bottom Line: Most patients with isolated traumatic hyphema do well. Nothing seems to effect visual acuity. There may be a benefit with antibrinolytic agents to prevent re-bleeds but delays resolution of primary bleed and has side effects. There is also no evidence for non-medical interventions. The ED management of traumatic hypemas would be to prescribe nothing and call ophthalmology.
Case Scenario Conclusion: This young man who was out for a night of quiet conversation and drinks and was “doing nothing” was refered to ophthalmology. He did not keep his outpatient appointment. You know this because he re-presented to the ED three months later with his hyphema resolved with no visual complications. However, he now has a painful swollen fifth MCP of his right dominant hand and you suspect a boxer fracture.
Last weeks winner was Allison Clark from Washington University in St. Louis. She is a second year ED resident and correctly identified that funnel plot are used to check for bias in systematic reviews/meta analyses. She had just learned this from the WashU ED Journal Club which was my #1 pick in the top FOAMed sites of 2012.
Listen to the podcast to hear this weeks Keener Kontest question.
Email your answer to TheSGEM@gmail.com. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize:)
It is now 2013 and time to take advantage of SkiBEEM 2013 Feb 4-6 at SilverStar BC. We will be presenting all the latest/greatest EBM reviews. This can cut your knowledge translation window to less than 1 year. We are even planning on even doing a live episode of TheSGEM as a PUBcast at the conference!
Don’t Panic…all bleeding stops…eventually. Remember to be skeptical of anything you learn, even if you heard it on The Skeptics Guide to Emergency Medicine. Talk with you next week.