Blunt eye injuries are common and may result from relatively trivial injuries or high-velocity impact projectiles. An exact history of the trauma must be obtained to assess the velocity involved, which in turn may indicate the extent of ocular damage. Inquiry must be made to determine whether visual acuity changes occurred immediately after the injury. Flashing lights are often seen at the instant of injury and indicate irritation of the retina, because any message to the brain from the retina is perceived as light. Persistent blurred vision is indicative of a more serious injury. It may indicate blood in the anterior chamber that is suspended in the aqueous humor. Free-floating blood in the anterior chamber is generally not appreciated by direct ophthalmoscopy. A slit-lamp examination is necessary to observe the suspended red blood cells in the anterior chamber.
Black Eye (Eyelid Contusion)
A black eye may be serious or relatively minor. If accompanied by severe pain, bleeding, or constant blurred vision, more serious eye trauma must be considered. In such patients, orbital CT scan and ophthalmologic consultation may be necessary to rule out a ruptured globe.
Almost all ocular trauma cases include bleeding or dilation of blood vessels on the surface of the eye (subconjunctival hemorrhage). This may be observed with any degree of eye
injury. For example, a subconjunctival hemorrhage may be spontaneous and often indicates minor injury. In the presence of other findings, a subconjunctival hemorrhage suggests more serious injury, particularly if a concomitant hyphema or vitreous hemorrhage is present.
Blunt trauma to the eye may result in lacerations of the sphincter muscle of the pupil. These are manifested by traumatic mydriasis. Unlike the unequal pupils seen with congenital anisocoria, traumatic mydriasis is characterized by recent onset of unequal pupils and by the irregularity of the dilated pupil. Although traumatic mydriasis by itself is not harmful, it suggests severe blunt trauma and is an indication for a careful assessment of other ocular structures, including the vitreous and retinal periphery.
Blunt trauma to the eye may cause injury to the iris, angle structures, and other intraocular structures. Hemorrhage into the anterior chamber, or hyphema, is most often found in children. The agent producing the hyphema is usually a projectile that strikes the exposed portion of the eye. A great variety of missiles and objects may be responsible, including balls, rocks, projectile toys, air gun, paint balls, bungee cords, and the human fist. With the increase of child abuse, fists and belts have started to play a prominent role. Boys are involved in 75% of cases.
Rarely, spontaneous hyphemas occur and may be confused with traumatic hyphemas. Spontaneous hyphemas are secondary to neovascularization, ocular neoplasms (retinoblastoma), and vascular anomalies (juvenile xanthogranuloma). Vascular tufts that exist at the pupillary border have been implicated in spontaneous hyphema. A traumatic hyphema may be graded by measuring the height of the layered hyphema in the anterior chamber in millimeters. A hyphema is an ocular emergency and should be referred immediately.
Cataract, choroidal rupture, vitreous hemorrhage, angle recession glaucoma, and retinal detachment are often associated with traumatic hyphema and compromise the final visual acuity prognosis. It is important to recognize that the prognosis for visual recovery from traumatic hyphema is directly related to three factors: (1) amount of associated damage to other ocular structures (e.g., choroidal rupture or macular scarring), (2) presence or absence of secondary hemorrhage, and (3) presence or absence of complications of glaucoma, corneal blood staining, or optic atrophy. With treatment, most hyphema patients have a good visual outcome. (See the discussion of hyphema grading and complications, as well as treatment and prognosis, online at www.expertconsult.com.)
Hyphemas are generally well managed with bed rest, shielding of the injured eye, and medical control of the hyphema and intraocular pressure (Crouch et al., 2009) (SOR: A). If IOP remains elevated or hyphema occupies more than 50% of the anterior chamber, surgical evacuation of the clot may be required to lower IOP, preserve corneal clarity, and reduce optic atrophy (Sheppard et al., 2009) (SOR: A).
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