Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Blunt eye injury and traumatic hyphaema

Blunt (closed-globe) trauma can injure the anterior segment, lens, retina and optic nerve. Traumatic hyphaema, the entry of blood into the anterior chamber after significant injury, can cause raised intraocular pressure (IOP), corneal blood staining, synechiae and optic atrophy, although permanent vision loss is uncommon [S7]. Trauma is a leading cause of monocular blindness, and a structured history and examination decide who can be reassured and who needs immediate referral [S6] [S8].

Key points - First decide whether the globe may be open; a suspected open globe needs immediate referral [S6]. - No medical treatment for hyphaema has been shown to improve visual acuity [S7]. - Antifibrinolytics (aminocaproic acid, tranexamic acid) reduce rebleeding, but the evidence is of low certainty and their effect on complications is unclear [S7]. - People with sickle cell trait or disease are especially susceptible to IOP rise and optic atrophy after hyphaema [S7]. - Look for late consequences: traumatic cataract, retinal detachment and cyclodialysis cleft with hypotony [S9] [S11] [S12].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Possible open globe within an apparently blunt injury: needs immediate referral for surgical repair [S6].
• Relative afferent pupillary defect (RAPD) or poor vision: check acuity and the pupils in every injured eye [S2].
• Sight-threatening retrobulbar haemorrhage: lateral canthotomy with cantholysis should be performed immediately [S2].
• Hyphaema in a person with sickle cell trait or disease [S7] [S5].
• Rebleeding, which increases the rate and severity of complications [S7].
• Infant or young child with retinal haemorrhages: multilayered, too numerous to count and extending from the posterior pole to the ora serrata are highly suspicious for abusive head trauma [S10].

Recognise it

• Common causes include sports, work-related trauma, road traffic accidents and explosions [S3] [S11]. Sports eye injuries have an estimated incidence near 15% [S3].
• Ocular trauma may involve the ocular surface and adnexa, extraocular muscles, orbital walls, eye and optic nerve [S6].
• Hyphaema: blood in the anterior chamber after injury [S7].
• Lens injury: common after blunt or penetrating trauma and can impair vision [S9].
• Cyclodialysis cleft: detachment of the ciliary muscle from the scleral spur, most often after blunt trauma; it may cause persistent severe hypotony with choroidal detachment, folds, disc oedema and macular oedema [S1] [S12].
• Traumatic retinal detachment is a leading cause of trauma-related blindness worldwide [S11].
• Children: abusive head trauma can produce retinal haemorrhages, retinoschisis, subconjunctival haemorrhages, corneal injury and globe rupture [S10].

Confirm it

• Take a detailed history, then a complete ocular examination and, if indicated, imaging [S6].
• Measure visual acuity and test for an RAPD; examine under anaesthesia if necessary [S2].
• Bedside ultrasound can help diagnose vitreous haemorrhage, retinal and vitreous detachment, foreign bodies and retrobulbar haematoma when the fundus cannot be seen [S4].
• Cyclodialysis clefts are hard to diagnose; ultrasound biomicroscopy and anterior segment OCT can help, and more than one cleft may be present [S1].
• Suspected abusive head trauma: an ophthalmology consultation with indirect ophthalmoscopy should be completed, together with full examination, imaging and laboratory tests to exclude accidental and systemic causes [S10].

Manage it

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Tier A (primary care / no specialist)

• Use a structured approach to history and examination to decide on reassurance or referral [S6].
• Protect a possibly ruptured globe with an eye shield and refer [S2].
• For hyphaema, non-drug measures such as patching, bed rest and head elevation are not supported by evidence: single versus binocular patching and bed rest versus walking made no difference to rebleeding [S7]. Refer any hyphaema to an eye clinic (see table).

Tier B (general eye clinic)

• Hyphaema, medical options (Cochrane review, 30 trials, 2969 participants) [S7]:
• No intervention improved visual acuity in the short or long term (low or very low certainty).
• Systemic tranexamic acid reduced secondary haemorrhage (RR 0.33; 7 trials, 754 participants), and systemic aminocaproic acid did so too (RR 0.28; 6 trials), although the aminocaproic acid result weakened in a sensitivity analysis.
• Aminocaproic acid increased nausea and vomiting and lengthened the time for the hyphaema to clear.
• Evidence on corticosteroids, cycloplegics and aspirin is too limited to support their use.
• Doses are not covered in the abstract; follow local formularies.
• Monitor IOP, rebleeding and corneal staining, with particular care in sickle cell disease [S7]. A narrative review offers a pragmatic approach, including management in children and sickle cell anaemia [S5].

Tier C (specialist centre)

• Traumatic cataract: the approach depends on age, mechanism of trauma and other conditions; early management matters in children because of amblyopia, inflammation and vitreoretinal adhesions [S9].
• Cyclodialysis cleft: a step-wise approach, conservative first, then laser or cryotherapy and surgery (direct cyclopexy, external plombage, vitrectomy with gas); there are too few studies to judge the safety and efficacy of these techniques [S1]. The aim is reattachment of the ciliary body and closure of the cleft [S12].
• Traumatic retinal detachment: managed by vitreoretinal services; there is no standardised definition beyond a preceding history of trauma [S11].
• A poor initial visual acuity does not guarantee a poor final result; the outcome can be predicted after approximately 3 to 4 weeks [S2].

Refer when

Pitfalls

• Missing an open globe hidden within a blunt injury [S6].
• Expecting patching or bed rest to prevent rebleeding [S7].
• Forgetting sickle cell status in hyphaema [S7].
• Judging the final prognosis on the first visual acuity [S2].
• Overlooking abusive head trauma in an infant with retinal haemorrhages [S10].

Evidence notes

• Thin evidence base. Only the Cochrane review [S7] is a systematic synthesis; all other sources are narrative reviews (expert opinion). Two abstracts give only a scope without findings [S5] [S8].
• The reduction in rebleeding with antifibrinolytics did not translate into a proven benefit for vision, and the long-term effects of secondary haemorrhage are unknown [S7].
• Not covered by these sources: IOP-lowering drug choices in hyphaema and sickle cell disease, surgical washout criteria, commotio retinae, choroidal rupture, angle recession glaucoma and follow-up intervals.

Related articles

• Open-globe injury
• Orbital fractures
• Traumatic optic neuropathy
• Rhegmatogenous Retinal Detachment

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.