A 35 year old otherwise healthy male presents 3 days after being struck in the left eye with a soccer ball while playing goalie. He is complaining of eye pain, eye redness, and near-complete vision loss in that eye. Physical exam revealed a completely normal right eye but the left eye has an unreactive, mid-dilated pupil, diffuse conjunctival injection, visual acuity only able to perceive light, and a 2 mm hyphema in the anterior chamber. No corneal abrasions, no foreign bodies, no proptosis, and no extraoccular motor restriction were noted. Pressures were found to be normal after CT scans.
We were concerned that the hyphema did not completely explain the severity of vision loss and the unreactive pupil. Thus, we consulted ophthalmology out of concern that this could be traumatic optic neuritis.
Differential diagnosis: Likely traumatic iritis with concurrent traumatic hyphema with concern for traumatic optic neuritis. Less likely is globe rupture.
CT Head/Face/Orbit: Negative for fractures, rupture, intracranial bleeds.
Take Away #1
Do not take traumatic hyphemas lightly! Permanent vision loss can happen even with Grade I (< 33%) hyphemas. A comprehensive eye exam by ophthalmology is indicated for all patients with hyphemas. This must happen emergently in the ED if the hyphema is Grade III/IV or if the patient has sickle cell disease, known coagulopathy, elevated intraoccular pressure, or concern for concurrent orbital compartment syndrome/globe rupture.
Take Away #2
ED management includes eye shield, bed rest, dim lighting, elevating the head of the bed, pain control (topical or systemic), prevention of vomiting (antiemetics), cycloplegias (only if there is no globe rupture or narrow angle glaucoma), and potential anticoagulation reversal. Topical glucocorticoid drops may be prescribed to prevent re-bleeding but evidence for this is weak.
Take Away #3
Don’t anchor on the diagnosis of hyphema! Always consider concurrent corneal abrasions, globe rupture, foreign bodies, traumatic iritis, conjunctival laceration.
Ryan Barnicle MD., M.Ed is a current third year resident at Stony Brook Emergency Medicine.
References:
Brandt, M. T., and R. H. Haug. 2001. “Traumatic Hyphema: A Comprehensive Review.” Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons 59 (12): 1462–70.
Edited by Bassam Zahid, MD