Neonatal bilateral hyphema: a rare presentation and clinical implications

Introduction: Neonatal hyphema, defined as intraocular bleeding into the anterior chamber, is a rare condition that requires immediate ophthalmologic evaluation. Unlike traumatic hyphema commonly seen in older children and adults, neonatal hyphema is typically associated with non-traumatic etiologies such as birth-related mechanical stress, hematologic disorders, congenital infections, or vascular anomalies. Bilateral involvement is particularly uncommon and necessitates a comprehensive systemic and ophthalmologic workup to rule out serious underlying pathology.

Case report: A female neonate was delivered at term via spontaneous vaginal delivery with normal Apgar scores and without perinatal complications. Shortly after birth, blood was observed in the anterior chambers of both eyes, more prominently in the right eye. Ophthalmologic examination confirmed bilateral hyphema with preserved corneal clarity. Systemic evaluation including complete blood count, coagulation studies, and TORCH serology ruled out coagulopathies and congenital infections. The patient was treated conservatively with topical atropine and corticosteroids. During hospitalization, the hyphema gradually resolved without evidence of elevated intraocular pressure or synechiae formation. The newborn was discharged with scheduled ophthalmologic follow-up to monitor for potential late complications.

Conclusion: This case underscores the importance of early recognition and multidisciplinary management of neonatal hyphema, particularly when both eyes are affected. Although birth trauma remains a common cause, thorough diagnostic evaluation is essential to exclude hematologic and infectious etiologies. Given the rarity of bilateral neonatal hyphema, additional case reports and studies are needed to enhance understanding of its etiology, optimal management, and long-term outcomes.

INTRODUCTION

Neonatal hyphema is a rare ocular finding. It is characterized by the presence of blood in the anterior chamber. In contrast to the more commonly encountered traumatic hyphema in older children and adults, neonatal hyphema is typically associated with non-traumatic etiologies such as birth-related trauma, coagulation disorders, or vascular anomalies [1]. The presence of bilateral hyphema in a neonate is particularly unusual and necessitates a thorough evaluation to identify or exclude underlying systemic or ocular disease [2].

Birth trauma is the leading cause of neonatal hyphema, often resulting from prolonged labor, forcepsor vacuum-assisted delivery, or excessive pressure on the infant’s head and eyes during vaginal birth [3]. However, spontaneous hyphema without a clear traumatic history raises concern for systemic conditions such as vitamin K deficiency, clotting factor deficiencies, or congenital infections [4]. Vitamin K deficiency, in particular, is a well-documented cause of neonatal bleeding and may present as hyphema, especially when prophylactic vitamin K administration is omitted or ineffective [5]. More rarely, congenital ocular abnormalities such as juvenile xanthogranuloma, persistent fetal vasculature (PFV) involving the iris, or retinoblastoma can also result in hyphema, requiring further ophthalmologic and systemic evaluation [6].

Although mild neonatal hyphema may resolve spontaneously without long-term consequences, complications such as corneal blood staining and secondary glaucoma can occur if the condition is not promptly recognized and appropriately managed [7]. Increased intraocular pressure due to clot obstruction of the trabecular meshwork represents a significant concern and may require treatment with pressure-lowering medications or, in severe cases, surgical intervention [8]. Corneal blood staining and the formation of synechiae can lead to permanent visual impairment if not treated in a timely manner [9].

This case report describes a newborn with bilateral hyphema at birth, emphasizing the diagnostic approach, therapeutic considerations, and clinical implications for visual development. Written informed consent for publication of this case report and accompanying images was obtained from the infant’s parents.

CASE REPORT

A female neonate was delivered at term via spontaneous vaginal delivery after an uneventful pregnancy. The 27-year-old mother was healthy, with no history of systemic disease, bleeding disorders, or medication use during pregnancy. The delivery was uncomplicated, and the infant’s Apgar scores were 9/9. At birth, the newborn demonstrated normal vital signs, weighed 3360 g, and was assessed as clinically stable. However, shortly after birth, blood was noted in the anterior chambers of both eyes, with more pronounced hemorrhage in the right eye (Figure 1). There were no external signs of trauma, periorbital edema, or subconjunctival hemorrhage. The red reflex was absent, particularly in the right eye, where the extensive hemorrhage prevented visualization of deeper ocular structures.

Figure 1. Top image: A neonatal eye presenting with spontaneous hyphema, characterized by the presence of blood in the anterior chamber without any apparent external trauma. Bottom image (7 days later): Noticeable improvement, with significant resorption of the hyphema. The anterior chamber appears clearer, with only minimal residual blood

The newborn was admitted to the University Eye Hospital for further evaluation and management. Ophthalmologic examination confirmed bilateral hyphema without corneal clouding. Pupillary reactions in the left eye were sluggish due to the hyphema but showed no afferent pupillary defect. The pupillary reaction in the right eye was assessed indirectly in comparison with the left eye. Visualization of the fundus was limited by the presence of blood; no posterior segment abnormalities were seen in the left eye, while the deeper structures of the right eye remained obscured. Ultrasonography confirmed the absence of intraocular tumors.

A comprehensive systemic workup was performed to exclude hematologic and infectious causes. Complete blood count, coagulation profile, and biochemical analyses were within normal limits, ruling out coagulation disorders such as vitamin K deficiency or clotting factor abnormalities. TORCH serology was negative, excluding congenital infections as the underlying etiology. Abdominal ultrasonography revealed no hepatosplenomegaly, further reducing the likelihood of a systemic infectious or metabolic disorder. Overall, the findings suggested that the hyphema was most likely induced during birth rather than caused by an underlying systemic disease.

The patient was treated conservatively with topical atropine 0.25% twice daily in the right eye to prevent posterior synechiae formation and topical prednisolone acetate 0.5% four times daily in both eyes to control inflammation and reduce the risk of complications. The infant was closely monitored for signs of elevated intraocular pressure or progression of hemorrhage. Over the following days, the hyphema gradually began to resolve, with partial improvement in the red reflex.

After seven days of hospitalization, the infant remained clinically stable, with no new findings suggestive of additional ocular pathology. The hyphema continued to resolve spontaneously, and intraocular pressure remained within normal limits, measured under general anesthesia using a handheld applanation tonometer (14 mmHg in the right eye and 15 mmHg in the left eye). The patient was discharged with instructions to continue topical corticosteroid therapy (four times daily in both eyes for two additional weeks), while cycloplegic treatment was discontinued after 14 days. Follow-up ophthalmologic examinations were scheduled to monitor for potential complications such as secondary glaucoma or corneal blood staining.

DISCUSSION

Neonatal hyphema is an uncommon but clinically important finding that requires urgent ophthalmologic evaluation to identify the underlying etiology and prevent potential complications. While hyphema in older children and adults is most commonly associated with blunt ocular trauma, the causes in neonates are more diverse and often nontraumatic. The most frequent etiologies include birth trauma, hematologic disorders, intrauterine infections, metabolic abnormalities and congenital vascular anomalies [1]. Bilateral hyphema in the neonatal period, as described in this case, is particularly rare and requires a detailed systemic and ophthalmologic assessment to exclude serious systemic disease.

Birth trauma is considered the leading cause of neonatal hyphema, especially in vaginal deliveries where excessive pressure may be exerted on the infant’s head and eyes during labor. Assisted deliveries, including vacuum extraction or forceps, can lead to elevated intraorbital pressure [2]. However, our case involved a spontaneous vaginal delivery, indicating that hyphema may occur even in uncomplicated births.

Another important aspect in the evaluation of neonatal hyphema includes hematologic disorders such as vitamin K deficiency bleeding (VKDB), thrombocytopenia and congenital coagulation factor deficiencies including hemophilia A and B [3]. VKDB is a well documented cause of spontaneous bleeding in neonates due to low vitamin K levels at birth, and it may manifest as mucosal, intracranial or intraocular hemorrhage [4]. In this case the newborn received prophylactic vitamin K at birth, and coagulation studies including platelet count, prothrombin time and activated partial thromboplastin time were normal, making a coagulation disorder unlikely.

Congenital infections, particularly those within the TORCH group (toxoplasmosis, rubella, cytomegalovirus and herpes simplex), can also cause intraocular hemorrhage due to associated chorioretinitis, retinal vascular abnormalities or congenital glaucoma [5]. However, in our patient, TORCH serology was negative, and no systemic or ocular signs suggested congenital retinitis or inflammation, effectively excluding an infectious etiology.

Other possible causes of neonatal hyphema include congenital ocular anomalies such as persistent fetal vasculature involving the iris, retinoblastoma and congenital glaucoma. Persistent fetal vasculature is a developmental anomaly resulting from failure of the fetal hyaloid vascular system to regress, which may lead to intraocular hemorrhage in newborns [7]. Retinoblastoma, although rare in neonates, must be considered in cases of unexplained intraocular hemorrhage, especially when leukocoria is present [8]. In our patient the cornea was clear and ultrasonography did not reveal any intraocular tumor that could explain the hyphema.

The main complications of neonatal hyphema include elevated intraocular pressure, corneal blood staining and secondary glaucoma, all of which may result in long term visual impairment. Elevated intraocular pressure may develop due to blockage of the trabecular meshwork by red blood cells or inflammatory debris, leading to secondary glaucoma [9]. Corneal blood staining may occur when hemolyzed erythrocytes remain in prolonged contact with the corneal endothelium and is a significant risk in cases of prolonged or recurrent hyphema [10].

Given the risk of these complications, management of neonatal hyphema is based on careful monitoring and supportive therapy. Conservative treatment with cycloplegics such as atropine is used to prevent posterior synechiae, while topical corticosteroids such as prednisolone acetate help reduce intraocular inflammation [11]. In this case the newborn was treated with atropine 0.25% and prednisolone 0.5%, which resulted in gradual resorption of the hyphema without complications.

Although spontaneous resolution is common in mild neonatal hyphema, regular ophthalmologic follow up remains essential [12]. Monitoring intraocular pressure is also required because some newborns may develop delayed secondary glaucoma even after the hyphema has resolved.

CONCLUSION

This case highlights the importance of a comprehensive diagnostic approach to neonatal hyphema, particularly when it presents bilaterally. Although birth trauma remains the most likely cause in vaginal deliveries, bilateral involvement requires a detailed systemic evaluation to exclude hematologic, infectious and congenital ocular pathologies. Conservative treatment with cycloplegics and corticosteroids is often sufficient, but careful monitoring is essential because of potential complications such as elevated intraocular pressure and corneal blood staining. Given the rarity of bilateral neonatal hyphema, additional case reports and studies are needed to improve understanding of its etiology, clinical course and optimal management strategies.