What Is Hyphema (Blood in the Eye)?

Hyphema is the medical term for bleeding in the anterior chamber of the eye—the space between the cornea and the iris. Most often a hyphema is the result of an injury such as a blow to the eye, although there are a number of diseases and conditions that can increase the risk of a spontaneous hyphema.

The pooling of blood is almost always visible to the naked eye and painful. It can interfere with vision and cause a dangerous increase in eye pressure, in which case a hyphema is considered a medical emergency that requires urgent medical attention to protect overall eye health and minimize the risk of permanent vision loss.

Depending on the severity of a hyphema, treatment can range from simple home care to surgery.

Hyphema Symptoms

It’s rare that a hyphema will not produce obvious symptoms, although very minor ones may only be visible with an eye exam and won’t hurt. Most hyphemas are unmistakable, however, and present with several obvious symptoms:

• Blood in the eye: If the hyphema is large, the eye may look as if it is filled with blood. This is because the bleeding discolors the clear fluid in the eye called the aqueous humor. Smaller hyphemas (microhyphemas) are not visible to the naked eye.
• Decreased vision: Depending on the amount of blood in the eye, vision may be obstructed to the extent that a person can only make out hand movements or detect the presence of light.
• Elevated eye pressure: The pool of blood may increase the pressure in the eye.
• Sensitivity to light: Photophobia, or sensitivity to light, can happen in the eye with the hyphema.
• Eye pain: Hyphemas tend to be painful.

Hyphemas are graded on a scale of 0 to 4 based on the amount of blood obscuring the cornea. The higher the grade, the more risk of intraocular pressure which can lead to glaucoma and vision loss.

Complications

The majority of people with hyphemas fully recover, but those with a high-grade hyphema are at increased risk of any of several serious complications:

• Recurrent bleeding: The eye may bleed again, depending on the extent of the initial trauma. Rest is important for preventing further bleeding.
• Glaucoma: Increased pressure in the eye may damage the optic nerve, resulting in glaucoma.
• Loss of vision: This may occur without prompt treatment of a hyphema.
• Stained cornea: The blood from a hyphema may stain the clear outer layer of the eyeball, permanently clouding vision.

Causes

A hyphema typically results from trauma to the eye, but it can also develop spontaneously and is associated with certain underlying medical conditions.

Traumatic Hyphema

A traumatic hyphema is a blunt or penetrating injury that can happen as the result of being hit in the eye with an object such as a ball, stick, fist, or elbow. It can also occur from the impact of a fall. Children are especially at risk while playing certain sports, such as baseball, basketball, softball, and soccer.

A hyphema is also a potential complication of eye surgery and requires treatment similar to that for traumatic hyphema.

Spontaneous Hyphema

Spontaneous hyphemas tend to occur in people with medical conditions that predispose them to blood or vascular problems:

• Neovascularization (growth of new blood vessels) caused by diabetic retinopathy or ischemia
• Eye tumors
• Eye melanoma
• Uveitis, inflammation of the uvea, which supplies blood to the retina
• Clotting disorders (hemophilia, von Willebrand disease)
• Sickle cell disease or trait
• Thalassemia, an inherited blood disorder that causes anemia
• Leukemia
• A history of eye trauma or eye surgery
• Iris chafing from intraocular lenses (lens implants)
• Eye infections from herpes virus

Diagnosis

It is important for an ophthalmologist to determine the cause of a hyphema. If there was trauma to the eye, they will need to know the details of the incident in order to first determine if the injury is an open globe injury—meaning something has penetrated or seriously injured the outer layers of the eye.

If it’s not a penetrating injury, the doctor will take a medical history and then examine the eye to determine if it is a hyphema or another cause of redness, such as uveitis (which again can result in a hyphema), conjunctivitis (an eye infection commonly referred to as pinkeye), or subconjunctival hemorrhage (broken blood vessels of the eye).

If a hyphema is suspected, the doctor will test visual acuity, measure intraocular pressure, and examine the eye with a slit lamp microscope and ophthalmoscope. In some cases, a computerized tomography (CT) scan may be necessary to fully examine internal eye structures.

Testing for sickle cell disease or other conditions that increase the risk of complications from a hyphema may also be done.

Treatment

Hyphema is a medical emergency that should not be treated without the help of an eye doctor. If you detect even a tiny amount of bleeding in your eye, with or without pain, or you get hit in the eye and think there’s a chance you’ve been injured, see a doctor. The severity of a hyphema determines how it should be treated.

Home Self-Care

In mild cases of hyphema, the body usually reabsorbs the blood within a few days, as long as certain measures are taken. These typically include bed rest with the head elevated 30 degrees to 45 degrees and wearing an eye patch. In some cases daily monitoring of eye pressure is advisable.

It's always best to err on the side of caution and get your eye examined by a healthcare provider as soon as you notice any blood inside your eye. A hyphema can lead to glaucoma or even permanent vision loss if not treated right away.

Prescription Medication

Topical eye medications—such as cycloplegics which prevent movement of the iris, and topical or oral corticosteroids to reduce inflammation—are commonly prescribed. Sedatives may also be used to minimize activity and reduce the chance of recurrent bleeding. Tylenol (acetaminophen) with or without codeine may be prescribed for pain.

Aspirin or blood thinners should be avoided if you have a hyphema, so tell the doctor who treats you if you take these medications regularly. It may be necessary to discontinue them for a few days if the doctor who prescribed them feels it will be safe to do so.

Surgeries and Specialist-Driven Procedures

Your doctor will want to examine your eye after a few days to make sure the hyphema is improving. If not or if the intraocular pressure increases, surgical removal of the blood may be recommended and hospitalization may be required.

Surgeries and specialist-driven procedures which may be used include:

• Anterior chamber washout: Two small corneal incisions are made, and a salt solution is irrigated through one port while the other evacuates the blood.
• Clot removal using an instrument: If an anterior chamber washout is unable to remove enough blood, a handheld irrigation/aspiration device or a vitrectomy instrument may be inserted to extract the clot.
• Trabeculectomy and iridectomy: With high-grade hyphemas or those that cause elevated pressure, a small hole may be made in the eye wall covered by a thin trap door-like flap to relieve pressure (trabeculectomy). Part of the iris may be removed as well (iridectomy). 
• Anterior chamber fluid-gas exchange: This technique, which can be performed in a doctor’s office, involves inserting two syringes into the eye—one to pump in gas, and the other to extract gas and fluid to remove the hyphema.

Follow-Up Care

If you experience a hyphema, avoid strenuous activity for at least a couple of weeks and keep all follow-up visits with your healthcare provider. Some complications of hyphema may not show up for several months, so your healthcare provider will want to see you regularly for eye exams. You should also be screened annually for glaucoma.

A Word from Verywell

A hyphema can occur after any trauma to the eye, but sports injuries are the most common. Wearing protective sports glasses or goggles can be an effective way to reduce the risk for athletes, particularly those who play sports where eye-related injuries are common. This includes basketball, water sports, baseball, and racquet sports. Protective eyewear may be annoying, but it’s worth it if it saves your sight.