Clinical case presentation

Dr. Samten Dorji

Chief complaint

• 26 year old male presented to the eye out patient department with stone piece injury to the left eye.

Personal details

He is from Punakha and working as farmer there. He is married and has 2 children.

History of presenting complaint

• On 28/09/2015 while working in a construction site a stone piece flew and hit his left eye

• He developed severe pain,redness, photophobia and reduced vision in the left eye after the incident.

• He was not using any protective eye wear.• There was no history of alcohol intake

prior to the incident

History continued

• Systemic review• Past ocular history/ past medical history/

ocular and systemic medications/ allergy history/family history

Right eye Left eyeVisual acuity 6/6 FCCFWith pinhole 6/6 FCCFColor vision normal Couldn't assess

Extraocular movements Normal Normal Lids and adnexa Normal Normal

Conjunctiva and sclera Normal Circumcorneal congestion

Cornea clear Horizontal linear abrasion 5mm lengthEndothelial dusting

Anterior chamber Normal depth and quiet

Normal depthHyphaema grade 1 cells grade 4+ and flare 3+

Iris and lens Normal Normal

Pupil Round regular and reactive

miotic

Fundoscopy Normal Normal (after hyphema got resolved)

IOP by I care 16 mmhg 11 mmhg

Case summary• A 26 year old male presented with pain,

redness, photophobia and reduced vision of the left eye after being hit by a stone piece. On examination right eye was normal. In the left eye vision acuity was FCCF. There was circumcorneal congestion and corneal horizontal linear abrasion. There was grade 1 hyphema, grade 4 cells, grade 3 flare in the anterior chamber and pupil was miotic. The posterior segment appeared normal

Diagnosis

• Left eye contusion type closed globe injury involving zone 2 structures (corneal abrasion + grade 1 hyphema + anterior uveitis)

Management

• Admission• Bed rest• Elevation of head• Eye shield• Antibiotic, cycloplegic and steroid eye

drops• Oral acetazolamide• IOP was monitored daily

Corneal abrasion, traumatic anterior uveitis and Traumatic hyphema

Dr. Samten Dorji

Corneal abrasionDefinition: breach of corneal epithelium (bowman’s membrane remain intact)

Epidemiology

• One of the most common globe injuries• 10% of ocular emergencies• Can accompany more extensive ocular

trauma

Pathophysiology

• Migration of peripheral cells onto the area of denuded basement membrane

• Proliferation of epithelial cells• Formation of hemidesmosomal attachments

Source of restoration= limbal stem cells

Clinical features

pain

photophobia lacrimation

Irregular corneal reflex Fluorescein staining of epithelial defect

Management • Patching • Antibiotic ointment or eye drops• Cycloplegic agent• Topical non steroidal anti

inflammatory drugs• Bandage contact lens

• Protect and cover the epithelium• Patient is able to see with the

affected eye during healing

Traumatic hyphema

Trauma

• Definition: blood in the anterior chamber after ocular trauma.

Epidemiology

Incidence rate 17-20//100,000

Age <20 years

Sex Male:female is 3:1

Common Aetiology Blunt object

Common source Sports (60%)

North America

USEIRRisk closed globe injury(35%)>open globe injury(31%)

Sex 80% of those injured are males

Mean age 29 years

Wearing proper eye protection could significantly reduce traumatic hyphaema

Classification

Grade Hyphema size

Grade 1 Layered blood occupying less than one third of the anterior chamber

Grade 2 Blood filling one third to one half of the anterior chamber

Grade 3 Layered blood filling one half to less than total of the anterior chamber

Grade 4 Total clotted blood, often referred to as blackball or 8-ball hyphema

Microscopic Circulating RBCs only

Pathophysiology Mechanism of injury

• Increase in intraocular pressure,• Equatorial stretching of the globe• Limbal stretching• Posterior pressure being transferred to

the iris

Associated clinical findings

• Angle recession• Cyclodialysis cleft• Traumatic iritis• Miosis• Mydriasis• Iridodialysis• Corneal changes• Cataract• Lens subluxation• Posterior segment injuries

Clot formation and dissolution

• IOP elevation, vascular spasm and formation of fibrin/platelet clot facilitate cessation of the bleeding

• Blood may extend from anterior chamber to posterior chamber• Maximum clot integrity(4-7 days)

Plasminogen Plasmin: breaks down fibrin • Clot degradation products, free blood cells and inflammatory debris clear through

trabecular meshwork outflow.

Evaluation

History

• History of trauma• Medical conditions: bleeding disorders, sickle cell disease, pregnancy, kidney

and liver disease

Glaucoma

Clinical examination• Suspect open globe injury until proven otherwise• Visual acuity• Tissue injury• Extent of hyphema• Intraocular pressure

Ultrasonography

Laboratory tests

Sickle status

• Bleeding tests: prothrombin time, partial thromboplastin time, platelet counts and bleeding time

• Renal function and liver function test

Radiological test

Treatment

• Medical and supportive treatmentReduce the rebleeding rateClearing the hyphaemaTreating the associated tissue lesionsMinimizing the long term sequelae

Inpatient Outpatient

Ease of follow up examination Patient’s preference

Increased compliance with medical therapy Less expensive

Restful environment

Earlier detection of complications

Inpatient vs outpatient

Supportive care

Bed rest

Medical care• Oral paracetamol as analgesics• No aspirin or NSAID• Cycloplegics• Miotics avoided • corticosteroids• Antifibrinolytic agents(avoided in sickle cell

haemoglobinopathy)• Fibrinolytic agents• Topical beta blockers and carbonic anhydrase

inhibitors• Oral carbonic anhydrase inhibitors

Surgical intervention

Traditional indication Current indication

IOP elevation >50mmHg for 5 days IOP doesn't respond to intensive medical therapy within 24 hours

IOP elevation >35mmHg for 7 days Patient has sickle cell disease or sickle trait

IOP elevation >25mmHg for 5 days in case of total/near-total hyphema

Early corneal blood staining

Large stagnant clots persisting for >10 days

Paracentesis and AC wash out

Advantages

• Ease of performance• Repeatability• Sparing of conjunctiva for future filtration

surgery• Providing for control of intraoperative

bleeding

Expression and limbal delivery for clotted hyphema

• Large limbal incision and violation of conjunctiva• Day 4-7

Bimanual cutting/aspiration for clotted hyphema

• Uses a vitrectomy probe• Tight control of intraocular bleeding• Allows anterior segment reconstruction

Complications

Rebleeding • Associated with higher complication rate• 2-5 days after injury(clot retracts and loosens)

• Large hyphemas• Young patients• Black patients• Hispanic patients• Patients taking aspirin• Presentation >24 hours

Glaucoma(acute)

•Impaired aqueous drainage through trabecular meshwork due to outflow obstruction by red blood cells,fibrin/platelet aggregrates and degraded cell products•Contusion damage to the trabecular meshwork and inflammation•Treatment to be initiated for IOP>30 mmHg in acute setting and persistent elevation of IOP >25mmHg for 2 weeks or more

• Topical and oral aqueous supressants

• Hyperosmotic agents• cycloplegics

Late

• Angle recession• Ghost cells• Formation of peripheral anterior

synechiae

Corneal blood staining

• Larger hyphemas• Rebleeding• Prolonged clot duration• Elevated IOP• Compromised endothelial function

Sickle cell disease

Sickle cells

Resistance to clearance through

trabecular meshwork

Increased IOPHypoperfusion of anterior segment

Hypoxia ,acidosis and hypercarbia

Difference in treatment

• More aggressive intervention to control IOP

• Avoidance of epinephrine derivatives• Miotics,Carbonic anhydrase and

hyperosmotic agents inhibitors are avoided

Prognosis and outcome

• >75% of hyphema eyes have >20/50 vision

• Rebleeding has been associated with poor vision

• Prognosis is poor in patients younger than 6 years

Traumatic anterior uveitis

• Inflammation of the anterior uveal structure especially the iris.

Epidemiology • Accounts for 20% of iritis in United states• Male > female• Affects younger age more

Clinical feature

Within 3 days

pain

photophobia tearing

Vossius ring

• Change in IOP• Pupil size

Iris bombe

Management

• Cycloplegic agents• Topical steroids• Follow up in 1 week and

1 month• Gonioscopy for angle

recession

• Prevent synechiae to lens• Prevent further protein

leakage• Prevent ciliary body and

pupillary spasm

Take home message

• In ocular trauma treat the patient as open globe injury until proven otherwise

• Shield protection• Pain relief• Activity restriction

Thank you