Case #2: Eye for an Eye

The Patient*

A 34 year old man was brought to the TEU Casualty Area ("The Pit") following a mob assault. Other than being a bit dazed and confused, the remainder of the primary survey was fairly unremarkable. His GCS was 13 (E3/V4/M6), and upon checking his pupils, the intern conducting the primary survey documented that the patient: "doesn't have a pupil on the right". Otherwise there were numerous bruises and abrasions to his head and body, but no other significant injury of note.

On closer inspection, it was later noticed that his right eye had the following appearance:

What are we seeing here?

Click to see the answer

This is a Grade IV hyphaema. There's also some subconjunctival haemorrhage and chemosis. An injury like this only has a 50-75% chance of recovering pre-morbid visual acuity [1]. You can also see my fluorescein staining (though no corneal defect was evident on cobalt blue filter).

If you don't recognise this pathology - how will you know to look for it? You miss 100% of the pathology you don't look for.

Management

We referred him to the ophthalmology service. They reviewed him and started him on a variety of topical agents, advised bed rest and head-of-bed elevation, and he was then transferred to the St John Eye Hospital, once other traumatic injuries were excluded.

Discussion

The reason this pathology gets missed is likely twofold. On the one hand, often small hyphaema will only become visible when the patient is sitting upright - this is what allows the fluid-fluid level to form between the blood and aqueous humour. We, of course, often see patients when they are supine in spinal precautions. On the other hand, we're also not very accustomed to seeing ocular trauma and there's probably a degree of "niche-ness" that means we overlook eyes as being a "specialty" issue. This should not be the case. As an intern working in the Pit, or as a registrar in the Resuscitation Room, it is our responsibility to identify these issues, even if an encyclopaedic sub-specialty knowledge of them eludes us. Interestingly, though hyphaema can sometimes present with somnolence (especially in children) and so may masquerade as traumatic brain injury (as it did here) - the presence of a hyphaema should never reassure you that an altered GCS is due to hyphaema alone.

Complications include:

1. Re-bleeding - this occurs as the initial clot begins to lyse in the first 2-5 days, causing a further episode of bleeding. These subsequent bleeds are often more severe.

2. Glaucoma - this occurs due to obstruction of the trabecular meshwork by clot, impeding the drainage of aqueous humour and causing raised intraocular pressure (IOP). This is turn causes permanent visual loss due to optic nerve damage.

3. Synechiae - these are post-inflammatory adhesions that form between the iris and other ocular structures, like the trabecular meshwork. Because they can make the iridocorneal angle more shallow they also pre-dispose to glaucoma.

4. Corneal staining - this is particularly problematic when it occurs within the visual axis (i.e. in front of the pupil) so is of particular concern in Grade III and IV hyphaema.

Management involves ophthalmology referral and treatment aimed at preventing each of the complications listed above.

1. Head-of-bed elevation allegedly helps reduce re-bleeding rate, though I couldn't find any strong evidence for this. Sitting them up will, however, reduce their IOP and for Grade I-II hyphaema will allow the blood to settle below the visual axis, thereby improving their vision and preventing staining in the most important section of cornea.

2. Oral tranexamic acid can reduce the risk of re-bleeding (RR 0.33, 95% CI 0.21-0.53) [2].

3. Avoid NSAIDs/aspirin, as these will interfere with platelet function and increase re-bleeding risk.

4. Topical homatropine 2% BD or cyclopentolate 1% TDS are examples of cycloplegics that can be used. In theory, by causing mydriasis there will be less pupillary "play" and therefore less irritation of the injured vessels to induce re-bleeding, plus they may prevent or break up synechiae that are forming, and they may increase patient comfort by reducing ciliary spasm if there is a degree of associated traumatic iritis.

5. Topical timolol 0.5% drops BD can reduce IOP, as they decrease aqueous humour production. If this is unsuccessful in reducing IOP to <25mmHg, then sometimes acetazolamide 250mg PO TDS is also used, though this should be avoided in patients with sickle cell as it can promote sickling.

6. Topical prednisolone acetate 1% BD-QID can be considered if there is significant post-traumatic inflammation, but be cautious if there are any concomitant corneal abrasions.

   
   

Note that there is fairly minimal evidence for corticosteroids, cycloplegics, head-of-bed elevation, or eye patching in terms of overall visual acuity outcomes [2].

Most patients with a Grade I or II hyphaema (i.e. <50%), normal IOP, no coagulopathy or haemoglobinopathy, and who will comply with instructions can get follow-up as an outpatient within 48 hours - though I would always run this decision past ophthalmology first. If IOP remains elevated despite maximal medical therapy or resolution is not occurring at the point of follow-up, then surgery may be indicated. Grade I has a good prognosis and the majority clear within 1-2 days, with 90% returning to pre-morbid visual acuity.

Patients with Grade III or IV hyphaema (i.e. >50%), raised IOP, coagulopathy, or patients with haemoglobinopathies (like sickle cell disease or even sickle cell trait) typically need admission for observation, regardless of grade. The reason for the latter is because sickled RBCs are much more likely to obstruct the trabecular meshwork and cause dramatic increases in IOP, even with lower grades of hyphaema. In this group, surgery is often required if IOP cannot be controlled <25mmHg within 24 hours despite maximal medical therapy. This is of particular importance in our patient population, because while sickle cell is less common in indigenous South Africans, 80% of all cases occur in Sub-Saharan Africa [3] and so prevalence is increasing due to increasing rates of immigration [4].

Take Home Points

• Examination of the eyes is an important part of the secondary and tertiary survey. If in doubt about your examination findings, ask.

• Hyphaema is a sight-threatening injury, and should be treated as such.

• Not much of what we can do is actually that beneficial, at least in terms of long-term visual acuity outcomes. What is important is having appropriate referral and follow-up, so that if there is non-resolution or persistently raised IOP then surgery can be performed before irreversible corneal staining or optic nerve damage can occur.

*Note that patient details have been changed for the purposes of de-identification.

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Dr Nick Chapman is a senior emergency medicine registrar, and has recently passed his written fellowship exams for the Australasian College of Emergency Medicine. He has a strong interest in both trauma and retrieval medicine, and completed his Postgraduate Diploma in Aeromedical Retrieval in 2021. He has previously worked at The Alfred Hospital's Emergency & Trauma Centre, but is hanging up his scrubs in favour of overalls as he heads to the Royal Flying Doctor Service.

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References

[1] Gragg J, Blair K, Baker MB. Hyphema. StatPearls [Internet]. 2022. Accessed 4th Aug 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507802/.

[2] Woreta FA, Lindsley KB, Gharaibeh A, Ng SM, Scherer RW, Goldberg MF. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2023;2023(3):CD005431.

[3] Adigwe OP, Onoja SO, Onavbavba G. A critical review of sickle cell disease burden and challenges in Sub-Saharan Africa. J Blood Med. 2023;14:367-76.

[4] Wonkam A, Ponde C, Nicholson N, Fieggan K, Ramessar R, Davidson A. The burden of sickle cell disease in Cape Town. S Afr Med J. 2012;102(9):752-4.