SAEM Clinical Image Series: Snowball Effects

A 13-year-old boy presented to the emergency department with complaints of a right eye injury. Five hours prior to arrival, he was struck directly in the right eye with a snowball resulting in immediate eye pain, localized swelling, some flashes of light in his vision and blurry vision. Prior to arrival, the patient had been seen at an optometry center where puff pressures of his eyes were obtained and the right eye was noted to have an increased intraocular pressure (IOP) of 46 mmHg compared to a pressure of 13 mmHg on the left. He continued to endorse photophobia and mild right eye pain.

Additional Images

Physical Exam

Eye:

No bony tenderness or crepitus surrounding the right eye
Positive blood fluid level in the anterior chamber
EOMI
On confrontation of visual fields, the patient was unable to count fingers in all fields on the right but could detect light and movement
Red reflex could not be elicited on fundoscopic exam
On fluorescein exam, no flow of aqueous humor and no corneal abrasions
Tono-Pen IOP measurements were 41mmHg in the right eye, and 27 mmHg in the left eye

Laboratory Data

Non-contributory

Case Question: What are the red flags in this patient's history and physical exam?

The red flags include a history of vision loss and the presence of ocular hypertension with the hyphema. Ophthalmology was emergently consulted for the intraocular hypertension. By the time of evaluation by the specialist, the patient stated that his vision was less blurry and he did not see any spots in his vision. The photos demonstrate progression of the traumatic hyphema from grade IV, to grade II, and then grade I.

Case Question: What emergent conditions need to be ruled out?

The emergent conditions that must be addressed include open globe and intraocular hypertension. Ophthalmology IOP measurements were 14 mmHg bilaterally. Visual acuities were 20/40 on the right and 20/20 on the left. A dilated eye exam with the slit lamp could not fully assess the posterior eye structures due to haziness. A metal eye shield was applied to the patient’s right eye, and he was discharged with cyclopentolate and prednisolone acetate eye drops, and an ophthalmology follow-up appointment within 24 hours. The patient was instructed to be on bed rest with the head of the bed elevated and to avoid straining.

Case Discussion

Take-Home Points

In traumatic eye injury, pay attention to eye color changes with grade IV hyphema which can be missed unless you compare it to the uninjured side.

Look for features of an open globe which include irregularly shaped pupils, delayed consensual light response, extrusion of vitreous, Seidel’s sign (fluorescein streaming of tears away from the puncture site).

Beware of intraocular hypertension (>21 mmHg) with high-grade traumatic hyphema which needs to be emergently addressed to prevent optic nerve atrophy and permanent vision loss.

References

Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70. doi: 10.1053/joms.2001.28284. PMID: 11732035.

Gharaibeh A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005431. doi: 10.1002/14651858.CD005431.pub2. Update in: Cochrane Database Syst Rev. 2013;12:CD005431. PMID: 21249670; PMCID: PMC3437611.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.