Hyphema in Dogs

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Hyphema is the presence of blood within the front (anterior) chamber of the eye and is a symptom of either serious ophthalmic or systemic disease. The amount of blood within the front chamber can vary. Mild hyphema may appear only as a pinkish-red discoloration to the fluid in the front of the eye, or as red blood settled out on the bottom of the chamber. Severe hyphema is when the entire chamber is filled with blood and the animal is rendered blind.

Hyphema usually originates from bleeding of the iris blood vessels, but the blood may also originate from the ciliary body (tissue behind the iris), choroidal blood vessels (tissue layer beneath the retina), or retinal blood vessels.

Causes

Some common causes of hyphema include:

  • Direct blunt or penetrating trauma to the head or eye
  • Choking or applying excessive pressure around the neck
  • Severe uveitis (inflammation of the iris, ciliary body and choroid)
  • Certain systemic infections, such as the tick-borne diseases
  • Blood clotting disorders
  • Systemic hypertension (elevated arterial blood pressure)
  • Retinal detachment or tearing
  • Chronic glaucoma
  • Tumors (cancer) within the eye
  • Congenital defects in the eye (rare)
  • In some animals the cause is never determined.

    Traumatic and congenital causes are more common in young dogs, while hypertension and most tumors are more common in older dogs. The other causes may occur at any age.

    What to Watch For

  • Redness within the eye located between the cornea (the clear front covering the eye) and the iris/pupil. The blood may hide a portion of the iris or pupil. It may settle to the bottom of the anterior chamber due to gravity, or it may form an actual blood clot in the chamber.
  • Other signs of trauma (bruising, wounds), inflammation or irritation (redness, discharge) to the eye
  • Possibly pain with squinting or holding the eye closed
  • Decreased vision or blindness in the affected eye(s)

    • A dog with hyphema secondary to very low numbers of platelets caused by an immune blood disease and resulting in poor ability to clot blood.

    • This geriatric dog was recently diagnosed with high blood pressure and secondary hyphema. The red blood cells have settled to the bottom half of the anterior chamber, allowing partial vision.

    Diagnosis

    Diagnostic tests may include one or more of the following:

  • Complete medical history and physical examination
  • Complete ophthalmic examination. This should include pupillary light reflex testing, Schirmer tear tests, staining of the cornea with fluorescein, tonometry (measurement of pressure within the eye), and examination of the front and back chambers of the eye under magnification
  • Complete blood count (CBC), including a platelet count
  • Serum biochemistry tests to look for involvement of other organs
  • Possibly a urinalysis
  • Specialized blood tests to evaluate the blood's ability to clot
  • Blood pressure testing
  • Specialized serum tests to detect the presence of certain infections or cancerous processes
  • Possible X-rays if there are signs of other organ involvement

    Treatment

    Treatment of the eye is often initiated while a diagnostic work-up is underway and may include:

  • Topical corticosteroids, in the form of eye drops or ointments, are used to reduce inflammation within the anterior chamber.

  • Topical atropine (1%), in the form of eye drops or ointments, is often indicated to dilate the pupil. Dilation of the pupil helps to relieve pain and to minimize adhesions between the iris and the lens.

  • Oral non-steroidal anti-inflammatory medications, such as aspirin or carprofen, are not initially used in most dogs with hyphema because these drugs may interfere with platelet function and increase the risk of further bleeding.

  • Treatment for glaucoma is indicated in eyes with elevated intraocular pressure. See the Client Education article on Glaucoma.

    Home Care

    Restrict your dog's activity and reduce the risk of further bleeding by confining your dog to a small room or crate until the cause of the hyphema is determined and the treatment is well underway.

    Because vision is impaired in some cases, do not allow your dog to go outdoors unattended or unsupervised.

    Do not administer human over-the-counter medications, such as Visine® or other ophthalmic products designed to reduce eye redness or irritation, because these products are ineffective for hyphema.

    Do not delay in bringing your pet to your veterinarian, because some causes of hyphema are not only vision threatening, but may also be also life-threatening.

  • Hyphema is the presence of blood within the anterior (front) chamber of the eye. Hyphema usually indicates bleeding from the iris blood vessels, but the blood may also originate from the ciliary body (tissue behind with the iris), choroidal blood vessels (tissue layer beneath the retina), or retinal vessels.

    Many dogs have some decrease in vision in the affected eye(s); however, if only one eye is involved, their behavior is usually normal. Eyes with hyphema may be painful, with symptoms of squinting, increased blinking and tearing. Trauma-induced hyphema is often accompanied by hemorrhages or bruising of the conjunctiva and tissues around the eye.

    Bleeding that is extensive or recurrent may completely fill the anterior chamber, resulting in total hyphema and blindness. Eyes with severe hyphema are at increased risk for developing glaucoma (elevated pressure within the eye) and must be monitored closely for this potential complication.

    Initially, the color of the blood within the eye appears bright red. The blood may remain unclotted and settle on the floor of the eye. The blood may also clot and turn dark brown or bluish-black with time.

    The presence of hyphema can either be a symptom of serious eye disease or a manifestation of some internal problem elsewhere in the body. While hyphema is often caused by trauma to the eye, spontaneous hyphema may occur with numerous different ocular and systemic disorders. Therefore, it is imperative that the cause of the hyphema be identified immediately.

    Prognosis for vision depends on whether the hyphema is mild or severe, whether the pupil can be effectively dilated during treatment, and whether there is bleeding or damage in the back of the eye as well. The presence of severe hyphema, failure to dilate the pupil, hemorrhages in the back of the eye or retinal detachment often results in blindness.

    Causes

    In general, the causes of hyphema fall into one of several categories:

  • Induced by blunt or penetrating trauma-related

  • Congenital defects within the eye (rare)

  • Chronic or severe uveitis, which is an inflammation of the iris, ciliary body, and choroid tissues of the eye

  • Blood clotting disorders from abnormalities in the number of function of platelets and other clotting factors

  • Systemic hypertension, which is an elevation in arterial blood pressure

  • Systemic diseases that effect blood clotting or the vessels of the eye, such as the tick-borne infections, certain leukemias, and severe elevations in serum proteins.

  • Retinal detachment and tearing of retinal vessels

  • Tumors or cancer within the eye or somewhere else in the body

    Specific causes that may be involved in the development of hyphema include:

  • Blunt trauma or injury through closed eyelids, as in automobile accidents, blows to the head, and horse-kick injuries

  • Sharp trauma or injuries that penetrate or perforate the eye

  • Proptosis of the eye, which is the forward displacement of the eyeball out of the orbit that usually arises from dog fights or blunt trauma to the head

  • Certain congenital defects within the eye, such collie eye anomaly, persistent blood vessels around the lens, and abnormal development of the vitreous and retina

  • Uveitis, with bleeding from vessels of the iris, ciliary body and choroidal tissues

  • Ehrlichiosis, a tick-borne infectious disease in the dog caused by Ehrlichia , E. canis, and other Ehrlichia spp. that results in the destruction of platelets and inflammation of blood vessels

  • Rocky Mountain spotted fever, a tick-borne disease caused by Rickettsia rickettsii, that results in symptoms similar, but milder than those caused by E. canis

  • Systemic hypertension (high blood pressure) associated with diseases of the kidneys and adrenal glands

  • Certain inherited blood clotting abnormalities, such von Willebrand's disease, platelet dysfunction, and the hemophilias

  • Accidental ingestion of rodenticide toxins, such as warfarin or brodifacoum, or the ingestion of rodents that have died from these toxins

  • Chronic liver disease with decreased production of coagulation factors and vitamin K

  • Coumadin toxicity from an overdose of this medication (prescribed for the treatment of certain cardiovascular diseases)

  • A decrease in the number of platelets (thrombocytopenia) from increased destruction (chronic inflammation, infection, auto-immune destruction) or inadequate production (bone marrow diseases) or a decrease in the function of platelets thrombopathia (secondary to a systemic disease or drug-induced process)

  • Hyperviscosity syndrome, which develops with extremely elevated levels of large protein molecules in the bloodstream

  • Primary tumors of the iris and ciliary body, or other tumors that originate within the eye

  • Metastatic tumors that have spread to the eye from other parts of the body

  • Retinal detachment with bleeding from the choroid and/or torn retinal vessels, resulting from eye trauma, systemic hypertension, uveitis, post-surgical uveitis (e.g. after cataract surgery), and chronic glaucoma resulting in enlargement of the globe with movement of the lens.

  • Diagnosis In-depth

  • A complete medical history is obtained and a thorough physical examination performed. Be sure to tell your veterinarian if you are aware of any potential exposure to toxins or poisons, any head or eye trauma, the rate of onset of the bleeding (sudden or slowly progressive), medications currently being given, ongoing medical conditions or recently observed physical abnormalities of your pet.

  • Complete ophthalmic examination usually includes examination of the interior of the eye under magnification, staining of the cornea with fluorescein, and tonometry to detect glaucoma. It is important to determine the extent of the hyphema, whether it is confined to the anterior chamber, whether the posterior part of the eye is also involved, and if the condition exists in one or both eyes. Your veterinarian may refer your dog to a veterinary ophthalmologist for further evaluation of the hyphema using specialized instrumentation.

  • Complete blood count (CBC) including a platelet count are performed to look for evidence of infection/inflammation and to ensure there are adequate numbers of platelets present.

  • A serum biochemistry panel is run to evaluate organ functions and to measure protein levels in the serum.

  • Specialized blood tests to evaluate blood clotting ability

  • Blood pressure testing determines if the dog has elevated blood pressure.

  • A urinalysis may be performed if there is a suspicion of kidney disease.

  • Chest and abdominal X-rays may be recommended if there is evidence of other organ abnormalities on the blood test results.

    Your veterinarian or veterinary ophthalmologist may recommend further diagnostic tests to search for other conditions in the body or to evaluate how much damage is present in the eye. Some commonly performed additional tests include:

  • Serology tests designed to detect the systemic tick-borne diseases, such as Ehrlichiosis, and Rocky Mountain spotted fever

  • Ocular ultrasonography, which is an imaging technique that shows the structures in the back part of the eye and behind the eye. This test is particularly helpful when the hyphema is so severe that the back part of the eye cannot be examined with the usual instruments. Ultrasonography helps to identify the presence of abnormal masses within the eye, lens displacement (luxation), retinal detachment or vitreal hemorrhage. A veterinary ophthalmologist or radiologist may perform or interpret of this test for your veterinarian.

  • Radiographs of the head and orbit (bony socket for the eye) may be necessary to identify fractures in dogs that have sustained head injuries. Plain X-rays are also useful to identify any metal foreign objects like gunshot pellets or BBs lodged in the area.

  • Hormonal assays of the adrenal gland may be recommended if high blood pressure was detected.

  • Abdominal ultrasonography may be recommended if there is evidence on the laboratory tests that certain organs in the abdomen are not functioning well, or that there may be cancer in the abdomen.

  • A bone marrow aspirate (cell collection from the bone marrow) may be done to evaluate the bone marrow's ability to produce platelets or to search for cancer of the bone marrow.

    Therapy In-depth

    The goals of treatment of hyphema are two-fold: to treat the inflammation that arises in the eye from the bleeding and to treat any underlying causes of the bleeding. Treatment of the hyphema itself involves the following:

  • Topical corticosteroids, in the form of eye drops or ointment, are used to reduce inflammation within the anterior chamber.

  • Topical atropine, in the form of eye drops or ointment, is indicated to dilate the pupil. Dilation of the pupil helps to relieve pain and to minimize adhesions between the iris and the lens.

  • Treatment for glaucoma, whether it initiated the hyphema or developed as a result of the bleeding, is indicated if pressures within the eye are elevated. See the Client Education article on Glaucoma.


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