PANCE Blueprint EENT (7%)

14 y/o with blurry vision, unequal pupils, and injected conjunctiva/sclera

Patient will present as → a 14-year-old who sustained a blunt trauma to his right eye after being struck by a baseball. He complains of blurry vision. On physical exam, you note unequal pupils, injected conjunctiva/sclera, and blood in the anterior chamber of the right eye.

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Trauma causes blood in the anterior chamber of the eye (between the cornea and the iris). The blood may cover part or all of the iris (the colored part of the eye) and the pupil, and may partly or totally block vision in that eye.

• The mechanism of injury varies by age ⇒ usually from blunt/penetrating trauma
  • Young children: baseball, softball, soccer, hockey, racquetball, etc.
  • Teenagers and adults: assault, paintballs, airbags, bungee cords, etc.
• In trauma ⇒ bleeding results from tears in the vessels of the ciliary body or iris
• In penetrating injury ⇒ bleeding results from direct damage to the iris
• If there is trauma you need to make sure there is no other type of injury – skull fracture, orbital fracture, etc., etc.

Hyphema with blood in the anterior chamber

Traumatic hyphema is a clinical diagnosis that is made based upon a history of eye trauma and characteristic findings during an ophthalmologic examination

• Orbital CT in patients with a suspected open globe or concern for serious orbital injury
• All patients with a traumatic hyphema warrant prompt evaluation by an ophthalmologist to provide expertise in comprehensive eye examination, including intraocular pressure measurement.

All patients with a traumatic hyphema warrant prompt evaluation by an ophthalmologist to provide expertise in comprehensive eye examination, including intraocular pressure measurement.

• Frequently blood is reabsorbed over a period of days to weeks
• Eyeshield - To avoid further injury to the affected eye, an eye shield should be worn at all times until the hyphema resolves or for at least one week 
• Elevate the head of the bed at 30 degrees all the time
• Patients with traumatic hyphema receive topical glucocorticoid eye drops
• Daily monitoring of intraocular pressure is a cornerstone in the management of traumatic hyphema
• NSAIDs are contraindicated as they may lead to increased bleeding into the anterior chamber
• Surgery if high pressure or persistent bleeding