A 19 y/o M was playing baseball and was accidentally hit in the eye with the ball. The patient is reporting eye pain and slightly blurred vision. On inspection in the ED his vision is 20/20 bilaterally, however this physical exam abnormality is appreciated.
Please identify the disorder seen in the attached picture. What genetic disorder, seen with higher prevalence in African-Americans, would increase the risk of developing ischemic complications of the retina and optic nerve?
Diagnosis: Hyphema - Layering of red blood cells in the anterior chamber; may be seen on visual inspection.
- Patients with sickle cell trait and disease are at greater risk for developing ischemic complications of the retina and the optic nerve; sickled red blood cells can more easily obstruct the trabecular meshwork and result in increased IOP (Intraocular pressure).
- Ophthalmology consultation is usually required; emergent orbital CT for patients with a suspected globe rupture, foreign body, or orbital injury
- Placement of an eye shield, elevation of the head to 30 degrees, Rx pain and vomiting, correct any underlying coagulopathy; if traumatic etiology give topical glucocorticoid eye drops.
- Patients with traumatic hyphema and increased IOP --> Topical alpha agonist (Brimonidine tartrate); Topical beta-blockers (Timolol Maleate); Prostaglandin analog (Latanoprost) --> decreased IOP
- If refractory to topical meds, add systemic meds in the acute phase --> Acetazolamide (contraindicated in patients with sickle cell anemia)
- Mannitol should be considered for persistently high IOP in spite of initial treatments
- In patients low-risk for thrombotic complications, antifibrinolytic (Amicar) therapy recommended
- Outpatient management possibly indicated, however admission suggested for patients with bleeding disorders, sickle cell anemia, active young children, patients with increased IOP on presentation,
delayed presentation, or more severe hyphema.
- Surgical clot evacuation indicated for severe cases refractory to optimal medical management.