Hyphema with Vitreous Hemorrhage

Pt fell and his eye hit a metal object. What is the diagnosis? • Xray of the Week

Figure 1. Non-contrast CT orbits – axial and sagittal images. What is the diagnosis?

Figure 2. Non-contrast CT orbits – axial and sagittal images. Hyperdense material consistent with blood fills the anterior chamber of the left eye (red arrows), indicating hyphema. Hyperdense material is also present in the vitreous chamber posteriorly (yellow arrows), consistent with acute vitreous hemorrhage. The right globe shows a normal lens separating anterior and posterior chambers (green arrows) for comparison.

Diagnosis

Traumatic hyphema with concurrent vitreous hemorrhage in the left eye.

Discussion

Hyphema is hemorrhage into the anterior chamber, most commonly from blunt or penetrating ocular trauma, but also possible from surgery, coagulopathy, or spontaneous causes (e.g., iris neovascularization).[1][2] Vitreous hemorrhage involves bleeding into the vitreous cavity, often linked to trauma, proliferative diabetic retinopathy, retinal tears, or vascular occlusions.[3]

In this traumatic case, both findings coexist due to shearing forces disrupting iris/ciliary body vessels (hyphema) and posterior structures (vitreous hemorrhage).

Hyphemas are graded clinically by the volume of layered blood in the anterior chamber (Table below). Grading helps predict complications like rebleeding (highest in grades III–IV) and secondary glaucoma.[4][5][6]

Hyphema Grade	Approximate Volume of Blood in the Anterior Chamber	Risk of IOP elevation/ secondary glaucoma
Grade 0: Microhyphema	<1% (slit-lamp only)	<10%
Grade I	<33%	~10%
Grade II	33–50%	~10%
Grade III	>50% but not full	~25%
Grade IV	100%	>50%
"Eight ball" hyphema	100% & dark color due to poor circulation	100%

Figure 3. Traumatic hyphema clinical image: Note the layering blood in the anterior chamber in this patient following blunt eye trauma. Contributor: Jesse Vislisel, MD - EyeRounds.org The University of Iowa. Creative Commons 3.0 https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Hyphema/index.htm#gsc.tab=0

Imaging Findings

Non-contrast orbital CT is the preferred initial imaging for acute ocular trauma when direct exam is limited by swelling, pain, or suspected open globe.[7][8]

• Hyphema appears as hyperdense (blood attenuation ~40–70 HU) material layering or filling the anterior chamber, anterior to the lens.[7]

• Vitreous hemorrhage shows increased attenuation in the posterior segment, often homogeneous acutely or heterogeneous if clotted/organized.[3][9]

Reported sensitivity for detecting hyphema on CT is ~77%, specificity ~88%.[7] CT excels at identifying associated injuries (e.g., lens dislocation, globe rupture, foreign bodies, orbital fractures) and is safer than ultrasound if open globe is suspected (to avoid pressure on the eye).[8] Ultrasound is superior for posterior segment details (e.g., retinal detachment) when media opacity from hemorrhage limits fundus view, but CT is first-line for trauma screening.[3][9]

Management & Prognosis

Management is primarily ophthalmology-directed. For traumatic hyphema: conservative measures include protective eye shielding, head elevation (30–45°), limited activity/bed rest, avoiding aspirin/NSAIDs/anticoagulants, and serial IOP monitoring to prevent rebleeding (peak risk days 3–5) or secondary glaucoma.[4][5][6][10]

Topical corticosteroids reduce inflammation; cycloplegics (e.g., atropine) relieve ciliary spasm/pain. Antifibrinolytics (e.g., tranexamic acid or aminocaproic acid) may reduce rebleeding risk but lack strong evidence for improving final visual acuity and can prolong clot clearance—use is controversial per recent reviews.[10] There are ongoing debates regarding optimal approaches due to the absence of standardized guidelines, including medical agents, surgical techniques, and special situations (e.g., sickle-cell disease).[8] Surgical evacuation (e.g., anterior chamber washout) is indicated for large/persistent hyphema causing corneal blood staining, uncontrolled IOP, or active rebleeding. Vitreous hemorrhage often resolves spontaneously but may require vitrectomy if non-clearing or associated with retinal pathology.[3]

Prognosis is generally good for isolated/low-grade cases (most resolve within days to weeks), but worse with higher grades, rebleeding, secondary glaucoma, sickle cell trait/disease, or extensive posterior involvement (e.g., retinal detachment). Approximately 5% of traumatic hyphemas require surgery.[4][5]

Key Learning Points

• Look for hyperdense anterior chamber fluid on non-contrast CT to diagnose hyphema in trauma.

• Vitreous hyperdensity indicates posterior hemorrhage; always assess for associated globe/orbital injuries.

• CT is valuable when clinical exam is limited; ultrasound complements for posterior evaluation.

• Grade hyphema clinically to guide prognosis and intervention—prompt ophthalmology consultation is essential to prevent vision loss.

References

1. Sung EK, Nadgir RN, Fujita A, et al. Injuries of the globe: what can the radiologist offer? Radiographics. 2014;34(3):764-776. doi:10.1148/rg.343135120

2. Hallinan JTPD, Pillay P, Koh L, Goh K, Yu W. Eye globe abnormalities on MR and CT in adults: an anatomical approach. Korean J Radiol. 2016;17(5):664-673. doi:10.3348/kjr.2016.17.5.664

3. Spraul CW, Grossniklaus HE. Vitreous hemorrhage. Surv Ophthalmol. 1997;42(1):3-39. doi:10.1016/S0039-6257(97)84041-6

4. Hartness E, Garza Reyes A, Yu C, Sears N. Hyphema: diagnosis and management. EyeRounds.org. February 20, 2024. Accessed January 14, 2026. https://eyerounds.org/cases/345-hyphema.htm

5. Chen EJ, Fasiuddin A. Management of traumatic hyphema and prevention of its complications. Cureus. 2021;13(6):e15771. doi:10.7759/cureus.15771

6. Miller SC, Meeralakshmi P, Fliotsos MJ, et al. Global current practice patterns for the management of hyphema. Clin Ophthalmol. 2022;16:3135-3144. doi:10.2147/OPTH.S372273

7. Chazen JL, El-Sayed IH, Vance S, et al. CT in the evaluation of acute injuries of the anterior eye segment. AJR Am J Roentgenol. 2018;210(3):W107-W113. doi:10.2214/AJR.17.18279

8. Bansal S, Gunasekaran PK, Azad S, Agrawal R. Controversies in the pathophysiology and management of hyphema. Surv Ophthalmol. 2016;61(3):297-308. doi:10.1016/j.survophthal.2015.11.005

9. Rabinowitz R, Yagev R, Shoham A, Lifshitz T. Comparison between clinical and ultrasound findings in patients with vitreous hemorrhage. Eye (Lond). 2004;18(3):253-256. doi:10.1038/sj.eye.6700632

10. Woreta FA, Lindsley KB, Gharaibeh A, et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2023;2023(3):CD005431. doi:10.1002/14651858.CD005431.pub5

Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.

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