Risk-Stratification Tool Guides Surveillance After Pediatric Closed-Globe Traumatic Hyphema
Key findings
- This retrospective study examined the timing of ocular hypertension (OHT) in 304 pediatric patients with closed-globe injury and hyphema
- At least one episode of OHT occurred in 39% of patients
- The vast majority of OHT episodes occurred in the acute period (≤7 days after injury), but numerous episodes also occurred in the subacute (8–28 days after injury) and late (>28 days after injury) periods as well
- Pupil damage at presentation predicted acute OHT; OHT at presentation predicted another episode of OHT during the subacute period; Iridodialysis and traumatic cataract predicted late OHT
- Vigilance is required to screen children for OHT after closed-globe injury with hyphema and a risk-stratification tool for surveillance of OHT is proposed
Ocular hypertension (OHT) is one of many complications that may arise from closed-globe injury with hyphema (blood collection in the anterior chamber). Because OHT can lead to glaucomatous damage and poor vision, providers recommend frequent follow-up evaluations, but these evaluations are based on local practice patterns, not evidence. These variations in care may lead to inequities in outcomes and may be burdensome if too frequent, especially when the patient is a child who has to miss school and a parent/guardian has to miss work.
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Ankoor S. Shah, MD, PhD, a pediatric ophthalmologist at Mass Eye and Ear, and colleagues conducted the first study showing the timing of OHT in children with traumatic hyphema. Using logistic regression analyses, they are able to present a risk-stratification tool to guide surveillance for OHT after injury. This algorithm is published in the American Journal of Ophthalmology.
Methods
The team retrospectively studied 304 pediatric patients (305 eyes) who sustained closed-globe injury and hyphema between January 2002 and April 2019, presented for treatment within three days of injury, and were followed for at least three visits and at least 21 days.
The median follow-up was 591 days, and 57% of patients had >180 days of follow-up.
Incidence of OHT
An episode of OHT was defined as an intraocular pressure measurement >21 mm Hg either at presentation or after a reading of ≤21 mm Hg at the prior visit.
175 individual OHT episodes were documented in 119 patients (39%). They occurred:
- At presentation (day 0): n=35
- Acutely (days 1–7 after injury): n=69
- Subacutely (days 8–28 after injury): n=35
- Late (>28 days after injury): n=36
Predictors of the Timing of OHT
Certain patient characteristics predicted the likelihood of OHT in each time period:
- Pupil damage at presentation predicted OHT during the acute period (OR, 3.01)
- OHT at presentation predicted a second episode of OHT during the subacute period (OR, 3.17)
- Iridodialysis (OR, 4.91) and traumatic cataract (OR, 8.22) predicted late OHT
Guidance for Surveillance
The risk-stratification algorithm proposed in the paper guides clinicians in surveillance for OHT in pediatric patients after closed-globe traumatic hyphema. However, it should be regarded as a starting point. A multicenter validation study is recommended to improve these recommendations.
Further caveats are that the algorithm:
- Should not be applied to surveillance of patients with grade 3 or 4 hyphema, comorbid conditions such as sickle-cell disease or trait, or episodes of symptomatic rebleed
- Assumes ophthalmologists will advise patients to return to the clinic before scheduled follow-up if there is a change in status
- Does not replace clinical judgment; for example, a patient with an intraocular pressure of 20 mm Hg in the injured eye and much lower in the fellow eye may not meet the definition of OHT but may merit close surveillance
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