Traumatic Hyphema: a Teaching Case Report
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Introduction he following case report is to be used as a teaching guide appropriate for third- and T fourth-year optometry stu- dents as well as optometry residents. The case report describes a patient with hyphema as a result of closed-globe in- jury who develops a number of associ- ated sequelae of blunt force trauma to include increased intraocular pressure, vitreous hemorrhage and angle reces- sion with iridodialysis. The paper dis- cusses appropriate management and treatment options as well as short- and Traumatic Hyphema: long-term complications of traumatic hyphema. This case demonstrates the A Teaching Case Report importance of identifying clinical find- ings related to poor visual outcome and Priscilla Lenihan, OD how to manage them appropriately. Dorothy Hitchmoth, OD, FAAO Learning Objectives At the conclusion of this case discus- sion, participants should be able to: 1. Discuss signs and symptoms of ini- tial presentation of traumatic hy- phema Abstract 2. Discuss appropriate treatment for Hyphema is the presence of blood in the anterior chamber of the eye and is most often the initial presentation of traumat- caused by blunt ocular injury. Hyphema, its complications and associated ocular ic hyphema injuries can pose a serious threat to vision and therefore require appropriate medi- 3. Recognize short- and long-term cal management and careful examination and follow-up. This teaching case report complications associated with trau- reviews the management of traumatic hyphema and discusses treatment options, po- matic hyphema tential complications and visual prognosis. 4. Recognize initial and long-term Key Words: traumatic hyphema, closed-globe injury, glaucoma medications, trau- clinical findings related to poor matic glaucoma visual outcome as a result of trau- matic hyphema 5. Discuss appropriate treatment op- tions for management of increased intraocular pressure (IOP) or glau- coma that results from hyphema or associated complications 6. Provide proper patient education on self-care needed to avoid com- plications. Key Concepts 1. Pathophysiology and natural his- tory of traumatic hyphema and its complications 2. Risk factors associated with poor visual prognosis Dr. Lenihan is a Staff Optometrist for the VA Maine Healthcare System at the Bangor Community Based Outpatient Clinic in Bangor, Maine. 3. The role of medication in reducing Dr. Hitchmoth is Chief of Optometry at the White River Junction Veterans Affairs Medical the risk of developing complica- Center in White River Junction, Vt. tions Optometric Education 110 Volume 39, Number 3 / Summer 2014 4. Medications, activities and diag- significant for diabetes mellitus type 2, corneas were clear of defect with nostic testing to avoid in the pa- hypertension, mixed hyperlipidemia, fluorescein staining and there was tient with traumatic hyphema. obstructive sleep apnea, insomnia, negative Seidel sign. Anterior chamber osteoarthritis, post-traumatic stress angles were open to grade III Van Discussion Points disorder and adjustment disorder with Herick OU. The anterior chamber of 1. Anatomical considerations of mixed anxiety. His list of medications the right eye was well-formed, clear closed-globe injury included aspirin, ibuprofen, and quiet. The left anterior chamber a. Cornea bupropion, tramadol, sertraline, was well-formed but 2+ red blood glyburide, metformin, lisinopril, cells and a hyphema that measured b. Anterior chamber and angle metoprolol, simvastatin, nifedipine a vertical height of 2.2 mm were c. Iris and ciliary body and prazosin. noted (Figure 1). The right iris was d. Vitreous and posterior pole normal and without rubeosis; the left Entering visual acuities without iris was dyscoric (irregularly shaped) 2. Treatment considerations (initial correction were 20/20 OD and 20/150 and free of rubeosis. Goldmann and subsequent) OS. The right pupil was round and tonometry revealed pressures of 14 a. Worsening of the condition responsive to light and measured mmHg OD and 18 mmHg OS. b. Development of complications 2.5 mm. The left pupil was fixed, The patient was dilated with two mid-dilated, and measured 4.0 mm. drops of 1.0% tropicamide and two c. Improvement of the condition Extraocular muscles (EOMS) were drops of 2.5% phenylephrine OS. d. Contraindications and side ef- smooth, accurate, full and extensive No clear view of the left fundus was fects of medication (SAFE) OU. There was no irregularity observed with either binocular indirect of the left orbital bone or sinus 3. Clinical examination ophthalmoscopy (BIO) or 90D lens crepitus on palpation of the orbit and due to the debris in the anterior a. Slit lamp and fundus examina- adnexal structures. Slit lamp exam tion chamber. A B-scan ultrasonography revealed clear lids and lashes OD was performed OS, which revealed b. Ocular ultrasound and mild edema and hematoma of no retinal detachment, vitreous c. Gonioscopy the upper and lower left lids without hemorrhage or subluxated lens. lacerations. The sclera and conjunctiva d. Imaging of the globe, orbit were clear of defect or hemorrhage The patient was diagnosed with and adnexal structures OD. The left eye showed a traumatic hyphema OS and was 4. Visual prognosis subconjunctival hemorrhage involving prescribed prednisolone acetate 1% a. Complications and associated the entire bulbar conjunctiva. The ophthalmic solution QID OS and injuries b. Risk factors Figure 1 Patient RM seen with a hematoma of the upper and lower lids, c. Medical and surgical interven- dense subconjunctival hemorrhage and grade 1 hyphema of the tion. left eye. Case Description Patient RM, a 60-year-old Caucasian male, presented to the eye clinic at the White River Junction Veterans Affairs Medical Center on Aug. 21, 2012, complaining of severe pain, blurred vision and sensitivity to light in the left eye. The patient reported someone threw a rock at him that hit his left eye the previous evening around 7 p.m. The patient had glasses, but was not wearing them at the time of the injury. RM denied flashes and floaters. RM was an established patient at the eye clinic. His ocular history included a branch retinal vein occlusion in the right eye diagnosed in 2010, early bilateral cataracts and mild non- proliferative diabetic retinopathy without clinically significant macular edema OU. His medical history was Optometric Education 111 Volume 39, Number 3 / Summer 2014 atropine sulphate 1% ophthalmic stable. An orbital X-ray was ordered TID. Acetazolamide 500 mg PO BID solution BID OS. RM was released and was negative for orbital or other was added to the patient’s medication from the clinic and given instructions facial bone fractures. Medication regimen, which otherwise remained for self-care at home. He was educated and instructions remained the same the same. Patient medical history, in- to shake the bottle of topical steroid with the exception that timolol 0.5% cluding allergies and kidney function, before instillation. He was also given ophthalmic solution was replaced was carefully reviewed prior to initiat- a non-pressure eye patch to reduce with dorzolamide 2%/timolol 0.5% ing oral acetazolamide. The patient photophobia when outdoors or in (Cosopt) BID OS. The patient was was also educated on the side effects bright light only. In addition, the instructed to return to clinic in two of acetazolamide to include increased patient was given a pair of clear days and to continue all other self-care urination, metallic taste and tingling in protective goggles to be worn during instructions. the extremities. IOP remained elevated sleep. He was instructed to sleep at an at 36 mmHg OS the following day. angle of approximately 45 degrees, to Summary of Visits and Pachymetry revealed thick and asym- rest as much as possible, and to avoid Clinical Outcomes metric corneas (607 um OD, 662 um any strenuous activity. A follow-up OS); thickness was significantly greater The traumatic hyphema slowly resolved appointment was scheduled for 24 in the left eye due to corneal edema that after nine days. The anterior segment, hours, and the patient was instructed to had developed. The patient’s medica- level of hyphema and IOP were moni- return to clinic sooner if he developed tion was kept the same, and the follow- tored at each visit. Retinal examina- visual changes or increased pain. ing day his IOP dropped to 21 mmHg tions through direct fundoscopy and OS. Over the next several visits, vision B-scan (Figure 2) continued through- The following day, RM reported the continued to improve, anterior seg- out the course of follow-up as well to pain in the left eye had improved. He ment inflammation and corneal edema monitor for cystoid macular edema was using his drops as instructed and slowly resolved, and intraocular pres- and to ensure the vitreous hemorrhage had worn the protective goggles at sure dropped and stabilized. Predniso- was resolving without additional com- night. RM denied flashes but noted lone acetate 1%, Cosopt and acetazol- plications such as retinal tear, retinal that vision in the left eye fluctuated. amide were correspondingly tapered detachment or vitreoretinal traction. Visual acuity was measured at 20/80-2 and discontinued. See Appendix A A complication encountered during OS; EOMS were SAFE OU. There was for a detailed account of the patient’s resolution of the hyphema was a rise in no pain or crepitus on palpation of the pertinent exam findings. Final best cor- IOP. One week after the initial trauma, left orbit and adnexa. Anterior segment rected visual acuity was 20/20- in the intraocular pressure increased to 34 exam was the same with the exception left eye. of the hyphema which was measured mmHg OS despite the use of Cosopt at 2.1 mm. IOPs were measured to be Gonioscopy was performed 12 weeks 14 mmHg OD and 26 mmHg OS. The lens was well-positioned with mild nuclear sclerotic cataracts in both Figure 2 eyes. BIO of the posterior segment OS B-scan of the left eye taken nine days after the initial trauma revealed diffuse vitreous hemorrhage showing a mild, diffuse vitreous hemorrhage seen as short lines with coagulation noted to be greatest in and faint dots within the vitreous cavity.