Case Study 24: 42-year-old man with left eye pain and redness

HPI
Patient is a 42-year-old African American man that was recently elbowed in the face during an altercation. He was not wearing any protective eyewear. He reports blurry vision and tenderness along his left eye, eyebrow, and cheekbone.

Past Ocular History
He has no pertinent ocular history. No history of spectacle use.

Ocular Medications
None

Past Medical History
Sickle cell trait, T2DM, HTN

Surgical History
None

Past Family Ocular History
No family history of glaucoma, macular degeneration, or other blinding diseases

Social History
Drinks alcohol socially, no tobacco or illicit drug use

Medications
Metformin
Glipizide
Aspirin 81mg
Hydrochlorothiazide

Allergies
No known drug allergies

ROS
Review of systems is negative except for above HPI

Ocular Exam

Visual Acuity (cc)
OD:20/20
OS:20/40

IOP (iCare tonometry)
OD: 15 mmHg
OS: 23 mmHg

Pupils
OD: 3mm in light and 5mm in dark. Pupil is round and reactive. Normal pupillary reaction. No rAPD.
OS: 6mm in light and dark. Pupil is round with a sluggish pupillary reaction. No rAPD.

Extraocular Movements
OD: Full, no nystagmus
OS: Full, no nystagmus

Confrontational Visual Fields (Toys)
OD: Full to finger counting
OS: Full to finger counting

Slit Lamp:

Dilated Fundus Examination:

Imaging/additional tests:
CT orbit: Round globes. No orbital fracture. No intraorbital pathology. Mild L upper lid edema.

Diagnosis
Traumatic hyphema – Grade II
i. Given patient’s history of recent trauma and exam findings, traumatic hyphema is the most likely diagnosis.

Definition
Hyphema is defined as the collection of blood in the anterior chamber. As enough blood begins to accumulate, it can precipitate in the inferior angle and begin obstructing anterior segment structures. Hyphemas are classified based on the amount of anterior segment that they are obstructing. Grade I is blood occupying < 1/3 anterior chamber volume, grade II is 1/3-1/2 of anterior chamber volume, grade III is > ½ of anterior chamber volume, and grade IV is blood occupying the total anterior chamber volume. Bleeding usually occurs due to the rupture of ciliary vessels following blunt force trauma; however, it can occur spontaneously as well. 70% of hyphemas occur in children.

Differential Diagnosis
Globe rupture
Globe ruptures are severe ocular emergencies and typically occur following blunt force trauma to the eye, as seen with this patient. Globe ruptures can also feature hyphema, decreased visual acuity, and have a positive Seidel test indicating aqueous humor leakage due to a ruptured globe. This diagnosis is less likely due to the CT scan results indicating round, intact globes with no intraorbital pathology. Also, IOP would also be low in the setting of globe rupture. 23 mmHg is considered elevated (<21 mmHg is considered normal), however it is not markedly elevated at this time. It is also very important to first rule out globe rupture when there is a high clinical suspicion before proceeding with a comprehensive eye exam, especially with measuring IOP which can apply unwanted pressure on the globe.

Orbital fracture
Orbital fractures can occur following blunt trauma to the orbit and can also be associated with hyphema and periorbital ecchymosis. This patient does have a hyphema , however only has mild edema present on physical exam and no substantial periorbital ecchymoses. CT scan also did not reveal any orbital fractures, and physical exam revealed no “step offs” or elicited tenderness to palpation over orbital rim. EOM movements were intact as well, with no restricted movements or pain with movements.

Traumatic Iritis
Traumatic iritis is another possible diagnosis; however, it is less likely at this time. Traumatic iritis can present with anterior chamber cells, pain, and photophobia. This patient lacks any photophobia. Iritis is due to inflammation of iris and ciliary body and usually has a delayed onset of 3-5 days after trauma.

Lens Dislocation
Lens dislocation is another possible diagnosis and can occur following blunt trauma to the eye and orbit. This frequently leads to visual disturbances and can result in hyphemas. Although this patient does have decreased visual acuity, this is not always present in patients with lens dislocations. Some patients continue to have 20/20 vision with a completely dislocated lens. Lens dislocations are also frequently associated with monocular diplopia and iridodonesis; both of which were not noted on physical exam.

Neovascular Glaucoma
Neovascular glaucoma is growth of new, abnormal blood vessels in the anterior chamber angle and iris. This often occurs in response to ischemic retinal conditions to include diabetic retinopathy or central retinal vein occlusion. Additionally, a hallmark symptom of neovascular glaucoma is increased IOP. The new vessels that develop are prone to bleeding and can lead to the development of spontaneous and traumatic hyphemas. Even though the patient in this case has developed a hyphema, neovascular glaucoma is not as likely given the relatively normal/slightly elevated IOP and lack of neovascularization appreciated on physical exam. It is much more likely the hyphema is a result of direct trauma and not due to underlying neovascularization.

Examination/Diagnostics
A thorough history and initial assessment are very important in the diagnosis of traumatic hyphemas. Detailed history of the trauma, visual acuity testing, and thorough external physical examination to attempt to identify any signs of globe rupture or orbital fractures are imperative. Ruling out globe rupture is one of the most important initial steps in evaluation and must be done prior to continuing certain parts of the ophthalmic exam to include tonometry. Slit lamp examination is used to evaluate the anterior segment of the eye and is an important next step in the examination of traumatic hyphemas. Slit lamp examination allows for the extent of the hyphema to be evaluated and to identify any additional injuries such as corneal abrasions, lens dislocations or iridodialysis. IOP should also be assessed once globe rupture has been ruled out. Fundoscopic examination is useful to evaluate the posterior segment for injuries such as retinal detachment or vitreous hemorrhages. Other examination modalities such as gonioscopy can be used to assess the angle structures if there are concerns for angle recession or neovascularization of the angle for alternative etiology of hyphema such as neovascular glaucoma. Imaging is usually not as indicated for the evaluation of the hyphema, however it is useful to rule out other injuries like globe rupture, orbital fractures, or other abnormalities like extraocular muscle entrapment. Ultrasound is contraindicated until globe rupture can be ruled out, as increased pressure due to ultrasound probe can further exacerbate injury and aqueous humor extravasation. Screening for coagulopathies and hemoglobinopathies such as sickle cell may be indicated depending on factors such as patient race or history of bleeding/clotting issues.

Treatment
Treatment and management of traumatic hyphema includes protecting the injured eye and avoidance of activities that could increase IOP. Placing a rigid eye shield over the eye for increased protection and avoidance of reinjury and advising bed rest with head elevation are important aspects of treatment. Head elevation is important to allow the blood to settle inferiorly in the anterior chamber and impede as few visual axis structures as possible. Although strict bed rest has been a part of the management for traumatic hyphemas, specifically to avoid the risk of rebleeding, there are some studies that have demonstrated there to be little difference in outcomes/rebleeding in patients who partook in quiet ambulation, patching, and head elevation versus the strict bed rest, patching, and head elevation management strategy. Non-NSAID analgesics should be used for pain relief as NSAIDs can increase the risk for further bleeding. Cycloplegics (i.e. atropine, scopolamine) and topical steroids can be used to treat associated iritis and to prevent synechiae. If there is increased/elevated IOP, topical beta-blocker therapy is first line for control. First line therapy is usually medical and non-surgical. However, patients with persistently elevated IOP, corneal blood staining, or non-resolving hyphemas are all indications for surgical interventions. Patients should be closely followed up with in the short term (1-2 weeks) to monitor IOP and ensure no rebleeding has occurred. The highest risk for rebleeding is within 2-5 days of the original injury. Prognosis for hyphemas can range from poor to excellent depending on the severity (grading) of the hyphema and mechanism of injury. Rebleeding has been associated with a worse prognosis. Other complications from traumatic hyphemas include posterior and peripheral anterior synechiae, corneal blood staining, glaucoma, and even optic nerve atrophy. Long-term, patients should be seen annually to ensure adequate control of IOP and to monitor the development of other ocular pathology. In the setting of patients with sickle cell disease or trait, hospital admission is recommended and strict IOP control is desired. An IOP > 25 mmHg for more than 24 hours is indication for surgical intervention in patients with sickle cell disease or trait.

1. In patients with a history of trauma and blood in the anterior chamber, what must first be ruled out before proceeding with a comprehensive physical exam?
a. Bacterial conjunctivitis
b. History of topical latanoprost use
c. Family history of hemophilia
d. Globe rupture
e. Uveitis

2. What laboratory test(s) should be considered when managing African American patients with hyphemas?
a. GFR and creatinine clearance
b. Sickle cell trait/disease status
c. PT and aPTT tests
d. CBC
e. CMP

3.A 22-year-old male presents to the emergency department after being hit in the eye with a baseball. On examination, his visual acuity is 20/40 in the affected eye. The eye is red and swollen, and there is a hyphema present. What is the most appropriate initial management step for this patient?
a. Administer systemic corticosteroids and arrange for an ophthalmology consult
b. Apply a patch to the affected eye and advise rest
c. Prescribe topical antibiotics and arrange for follow-up in a week
d. Perform a complete ophthalmologic examination, including tonometry
e. Initiate oral analgesics and discharge the patient with instructions to return if symptoms worsen

4. A 35-year-old woman presents with a hyphema following a domestic accident. She has no significant past medical history, and her examination is otherwise unremarkable. What is the most important factor to consider in her management to prevent complications?
a. Ensuring she avoids anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs)
b. Immediate surgical intervention to evacuate the blood
c. Encouraging vigorous physical activity to promote reabsorption of blood
d. Using topical antihistamines to reduce conjunctival inflammation
e. Providing a high-dose oral antibiotics to prevent secondary infection

5. A 16-year-old male presents with a hyphema following a sports injury. He reports seeing a red haze in his vision and experiences eye pain. What is the most likely long-term complication he should be informed about?
a. Cataract formation
b. Retinal detachment
c. Macular degeneration
d. Glaucoma
e. Uveitis

1. In patients with a history of trauma and blood in the anterior chamber, what must first be ruled out before proceeding with a comprehensive physical exam?
d. Globe rupture
Determining whether or not globe rupture has occurred is the first step in examination and management of a hyphema. Globe rupture is an ophthalmic emergency and must be addressed right away. If globe rupture is missed and the ocular examination proceeds normally, it can cause extravasation of the aqueous humor and can result in more damage to the eye.

2. What laboratory test(s) should be considered when managing African American patients with hyphemas?
b. Sickle cell trait/disease status
Determining sickle cell trait/disease carrying status in African American patients is very important when managing a hyphema. Those with sickle cell trait/disease, other hemoglobinopathies, and coagulopathies are at increased risk to develop spontaneous hyphemas and to experience rebleeding in the setting of traumatic hyphemas. They must be monitored more closely than someone without these risk factors.

3.A 22 year-old male presents to the emergency department after being hit in the eye with a baseball. On examination, his visual acuity is 20/40 in the affected eye. The eye is red and swollen, and there is a hyphema present. What is the most appropriate initial management step for this patient?
d. Perform a complete ophthalmologic examination, including tonometry
In cases of hyphema, a thorough ophthalmologic examination is critical to assess the severity of the hyphema, check for any additional injuries, and measure intraocular pressure (tonometry). Early intervention can help prevent complications such as increased intraocular pressure or vision loss.

4. A 35 year-old woman presents with a hyphema following a domestic accident. She has no significant past medical history, and her examination is otherwise unremarkable. What is the most important factor to consider in her management to prevent complications?
a. Ensuring she avoids anticoagulants and nonsteroidal anti-inflammatory drugs (NSAIDs)
To prevent complications such as rebleeding, it is crucial to avoid medications that can exacerbate bleeding, including anticoagulants and NSAIDs. Management typically involves monitoring and supportive care rather than immediate surgical intervention, unless there are additional complications.

5. A 16 year-old male presents with a hyphema following a sports injury. He reports seeing a red haze in his vision and experiences eye pain. What is the most likely long-term complication he should be informed about?
d. Glaucoma
One of the significant long-term complications of hyphema is glaucoma, which can develop due to increased intraocular pressure secondary to blood in the anterior chamber. Regular monitoring of intraocular pressure and appropriate management are essential to prevent or address this complication.

References/Resources:
Gragg J, Blair K, Baker MB. Hyphema. [Updated 2022 Dec 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507802/

Machiele R, Motlagh M, Zeppieri M, et al. Intraocular Pressure. [Updated 2024 Feb 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532237/

Mir, T., Iftikhar, M., Seidel, N., Trang, M., Goldberg, M. F., & Woreta, F. A. (2020). Clinical Characteristics and Outcomes of Hyphema in Patients with Sickle Cell Trait: 10-Year Experience at the Wilmer Eye Institute. Clinical ophthalmology (Auckland, N.Z.), 14, 4165–4172. https://doi.org/10.2147/OPTH.S281875

Wilker, S. C., Singh, A., & Ellis, F. J. (2007). Recurrent bleeding following traumatic hyphema due to mild hemophilia B (Christmas disease). Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 11(6), 622–623. https://doi.org/10.1016/j.jaapos.2007.06.009

Walton, W., Von Hagen, S., Grigorian, R., & Zarbin, M. (2002). Management of traumatic hyphema. Survey of ophthalmology, 47(4), 297–334. https://doi.org/10.1016/s0039-6257(02)00317-x

Rocha, K. M., Martins, E. N., Melo, L. A., Jr, & Moraes, N. S. (2004). Outpatient management of traumatic hyphema in children: prospective evaluation. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 8(4), 357–361. https://doi.org/10.1016/j.jaapos.2004.04.001

Iftikhar, M., Mir, T., Seidel, N., Rice, K., Trang, M., Bhowmik, R., Chun, J., Goldberg, M. F., & Woreta, F. A. (2021). Epidemiology and outcomes of hyphema: a single tertiary centre experience of 180 cases. Acta ophthalmologica, 99(3), e394–e401. https://doi.org/10.1111/aos.14603

Schmuter G, Armstrong GW, Justin GA. Yo need to know: 5 pearls for managing hyphema. American Academy of Ophthalmology. April 24, 2024. Accessed May 13, 2025. https://www.aao.org/young-ophthalmologists/yo-info/article/yo-need-to-know-5-pearls-managing-hyphema.

Hyphema grading system. American Academy of Ophthalmology. August 26, 2014. Accessed May 13, 2025. https://www.aao.org/education/image/hyphema-grading-system-2.

Gardiner M. Overview of eye injuries in the emergency department. UpToDate. August 26, 2024. Accessed May 13, 2025. https://www.uptodate.com/contents/overview-of-eye-injuries-in-the-emergency-department?search=lens+dislocation&usage_type=default&source=search_result&selectedTitle=2~25&display_rank=2#H1906648.
Hyphema. EyeWiki. February 27, 2025. Accessed May 13, 2025. https://eyewiki.org/Hyphema#:~:text=Traumatic%20hyphema%3A%20Blunt%20trauma%20to,nerve%2C%20and%20other%20intraocular%20structures.

Recchia FM, Aaberg T, Sternberg P. Trauma: Principles and techniques of treatment. Retina. Published online 2006:2379-2401. doi:10.1016/b978-0-323-02598-0.50146-4