A 23-year-old healthy male presented to the emergency department with left eye pain, soreness, and blurry vision after being hit in the left eye with a Nerf gun bullet two days prior. He had no prior ophthalmologic history and does not wear corrective lenses.
Left eye: Visual acuity 20/30. Intraocular Pressure 17. Pupil 3mm, irregular, minimally reactive. Slit lamp exam revealing 3+ RBCs, vertical layering of blood along the nasal aspect. None Vertical hyphema Blunt trauma induces shearing forces upon the vasculature of the ciliary body and iris, resulting in the accumulation of red blood cells (RBCs) in the anterior chamber. This space normally contains only clear, aqueous humor. RBCs slowly settle to the bottom of the anterior chamber in a gravity-dependent manner. Classically this develops in a horizontal pattern, but patients who subsequently sleep on their side may experience vertical hyphema formation. Although trauma is the most common etiology, hyphema can occur due to any hematologic abnormality. It is a frequent complication of sickle cell disease. As in all cases of ocular trauma, globe rupture must be immediately ruled out before proceeding with a comprehensive ophthalmologic examination. The patient had a Grade I hyphema. Grade 0: No visible layering, but red blood cells within the anterior chamber (microhyphema) Grade I: Layered blood occupying less than one-third of the anterior chamber Grade II: Blood filling one-third to one-half of the anterior chamber Grade III: Layered blood filling one-half to less than total of the anterior chamber Grade IV: Total filling of the anterior chamber with blood (also known as 8-ball hyphema)Take-Home Points
Copyright
Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.
Lance Shaull, MD
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