Hyphema with Vitreous Hemorrhage

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

Figure 1. What is the diagnosis?

Figure 2. (CT- Axial and Sagittal): Non-contrast CT of the orbits demonstrates hyperdense material consistent with blood in the anterior chamber (red arrows) of the left eye, indicating a hyphema. There is also hyperdense material in the posterior chamber consistent with acute vitreous hemorrhage (yellow arrows). Note the normal left lens separating the anterior and posterior chambers of the right globe (green arrows).

Hyphema with Vitreous Hemorrhage

Hyphema refers to hemorrhage into the anterior chamber of the eye, most often secondary to blunt or penetrating trauma, ocular surgery, or coagulopathy [1,2]. Vitreous hemorrhage represents bleeding into the vitreous body, typically associated with trauma, proliferative diabetic retinopathy, retinal tears, or other vascular etiologies [1,2].

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)

CT Imaging Findings

On non-contrast orbital CT, hyphema appears as a hyperdense collection filling or layering in the anterior chamber, anterior to the lens [2-5]. (Figs. 1,2) Clinically, blood is seen layering in the anterior chamber (Fig. 3). Reported sensitivity for hyphema detection is approximately 77%, with specificity of 88% [3]. Vitreous hemorrhage demonstrates increased attenuation within the vitreous chamber, which may appear homogeneous or heterogeneous depending on the chronicity and amount of blood [1,4].

CT is particularly useful when ophthalmologic examination is limited due to periorbital swelling, pain, or suspected open-globe injury. It also provides assessment for associated ocular or orbital trauma including lens dislocation, foreign bodies, or globe rupture [2,3]. Ultrasonography can be used to assess for posterior segment issues like retinal detachment or vitreous hemorrhage [6].

Treatment & Prognosis

Management is directed by ophthalmology. Traumatic hyphema is significant because it may lead to corneal blood staining, decreased corneal transparency, and vision impairment [3]. For hyphema, treatment is usually conservative including eye shielding, head elevation, and avoidance of anticoagulants. Surgical intervention may be required in cases of delayed clot resorption as this can lead to secondary glaucoma. Vitreous hemorrhage may resolve spontaneously, although persistent cases require vitrectomy. Prognosis is favorable for isolated cases, though risks increase with rebleeding, elevated intraocular pressure, sickle cell disease, or extensive posterior segment involvement [1,6].

References

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

2. Sung EK, Nadgir RN, Fujita A, et al. Injuries of the Globe: What Can the Radiologist Offer? Radiographics. 2014;34(3):764-776. https://doi.org/10.1148/rg.343135120

3. 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. https://doi.org/10.2214/AJR.17.18279

4. 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. https://doi.org/10.3348/kjr.2016.17.5.664

5. Gad K, Singman EL, Nadgir RN, Yousem DM, Pillai JJ. CT in the Evaluation of Acute Injuries of the Anterior Eye Segment. AJR Am J Roentgenol. 2017;209(6):1353-1359. doi: 10.2214/AJR.17.18279

6. 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. https://doi.org/10.1038/sj.eye.6700632

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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