Hyphema: Blood Inside the Eye After Trauma

Several different situations can lead to bleeding in the anterior chamber. Trauma is by far the most common cause, though medical conditions and prior eye procedures can also play a role. A direct blow to the eye from a ball, fist, airbag, or other object is the most frequent cause of hyphema. The force compresses the eye, tearing small blood vessels in the iris or ciliary body (the structure behind the iris that produces aqueous fluid). Penetrating injuries from sharp objects can also cause bleeding inside the eye and often require more extensive evaluation to check for additional damage. Similar forces that cause a hyphema can also result in an orbital fracture, which is why thorough imaging is sometimes necessary after significant eye trauma.

A hyphema can occasionally develop after intraocular surgery such as cataract removal or glaucoma procedures. Abnormal blood vessel growth on the iris, a condition called rubeosis iridis, can lead to spontaneous hyphema without any trauma. Blood clotting disorders, use of anticoagulant medications, and certain blood cancers such as leukemia are additional risk factors for non-traumatic hyphema.

One of the most important concerns with hyphema is the risk of a secondary bleed, known as a rebleed. This typically occurs three to five days after the initial injury when the original blood clot breaks down and the damaged vessel begins bleeding again. Rebleeds happen in roughly 15 to 20 percent of cases and can be more severe than the original hyphema, which is why close follow-up during the first week is critical.

Treatment focuses on keeping the eye still and preventing rebleeding. You will be asked to rest with your head elevated at about 30 to 45 degrees, and a rigid eye shield is placed over the eye for protection. Our ophthalmologists may prescribe dilating drops to keep the pupil still, topical steroid drops to control inflammation, and pressure-lowering eye drops if needed. Aspirin, ibuprofen, and other nonsteroidal anti-inflammatory medications should be avoided because they can increase the risk of rebleeding.

Beyond elevated eye pressure and corneal blood staining, hyphema can lead to peripheral anterior synechiae (scar tissue that permanently closes parts of the drainage angle) and optic nerve damage. In young children, a large hyphema that obstructs vision during a critical period of visual development can contribute to amblyopia (reduced vision from disuse). Identifying sickle cell status early in treatment is essential because these patients face a higher rate of complications even from small hyphemas.

A small hyphema (grade 1 or microhyphema) typically clears within five to seven days as the blood is gradually reabsorbed. Larger hyphemas (grade 3 or 4) can take two weeks or longer to resolve. The highest-risk period for rebleeding is between the second and fifth day after injury, so activity restrictions are especially important during that window.

You should avoid all strenuous physical activity, bending, lifting, and straining during the recovery period. Reading and screen time should be limited to reduce eye movement. Children with hyphema are typically kept home from school during the first week, and sports should not be resumed until our ophthalmologists confirm that the eye has fully healed.

Most patients with a small, uncomplicated hyphema recover their vision fully with proper treatment. However, larger hyphemas, those complicated by rebleeding, persistent high eye pressure, corneal blood staining, or associated retinal injuries carry a higher risk of lasting vision changes. Early treatment and careful follow-up are the best ways to minimize this risk.

Surgical intervention, known as an anterior chamber washout, may be necessary when eye pressure remains dangerously elevated despite maximum medical therapy, when a large clot does not begin to resolve on its own, or when corneal blood staining develops. Patients with sickle cell disease may require earlier surgical intervention because even moderate pressure elevations can damage the optic nerve. If you experience any type of foreign body injury or chemical exposure that could also involve bleeding inside the eye, seek emergency evaluation right away.