SAEM Clinical Images Series: An Interesting Case of Ocular Trauma

2024-08-19T10:01:53-07:00

Aug 26, 2024 | Ophthalmology, SAEM Clinical Images

By: Zachary Grant, MD and Fernando Benitez, MD |Editors: Jessica Hoglund, MD; Moises Gallegos, MD, MPH

ocular trauma

A 27-year-old male with no past medical history presents to the Emergency Department with right eye pain. He states that approximately one week prior, he was working on a wire fence when he lost hold of a wire under tension, and it subsequently hit him in his right eye. He had immediate pain in his affected eye and was unable to see anything but light for the next three days. His vision slowly improved though it never normalized. He continued to have pain, so he presented for evaluation. He also reported seeing floaters and denied pain with eye movement, increased light sensitivity, or eye discharge.

Additional Images

Physical Exam

Eyes: Lids without injury. Visual acuity was 20/50 OD, 20/30 OS. Intact visual fields to finger confrontation. Extraocular muscle movements were intact and without pain. Right pupil was oval-shaped and reactive, and an evident defect at the iris from the 9 to 11 o’clock position was noted. On fluorescein stain, there was no uptake, with a negative Seidel sign. Tonometry was normal (13 OD, 12 OS). On slit lamp examination, the patient had a clear cornea, an appropriately deep anterior chamber with no hyphema or hypopyon, and 1+ mixed cells. The lens was clear, with no movement or vibration (phacodonesis) noted. A vitreous hemorrhage OD was also identified on bedside ultrasound.

Laboratory Data

Non-contributory

Case Question: What is the diagnosis?

Iridodialysis

Traumatic iridodialysis is an uncommon ocular emergency with very distinct findings that we can encounter in the Emergency Department. It is most commonly seen with blunt trauma but can also occur with penetrating injury to the eye. This injury appears as a crescent-shaped defect at the peripheral area of the iris. Blunt trauma causes an acute globe compression, which temporarily increases intraocular pressure. This increased pressure is dissipated throughout the eye, leading to forceful fluid shifts that cause increased tension along the pupillary sphincter muscle. The weaker area of the sphincter muscle can subsequently tear, resulting in separation of the iris from the ciliary body.

Case Question: What is the next most appropriate management of this injury?

Iridodialysis can be managed conservatively if it is asymptomatic and uncomplicated. Complicating factors, which include elevated intraocular pressures refractory to medical therapy, the presence of a large hyphema, rupture from blunt trauma, or the need for exploration secondary to penetrating trauma, require an Ophthalmology consult and may require emergent surgical repair.

Case Discussion

Take-Home Points

Patients with iridodialysis are at risk for globe rupture, so a fluorescein exam must be performed prior to measuring intraocular pressure.
Ophthalmology should be consulted if the patient has complicating factors, which include elevated intraocular pressures refractory to medical therapy, the presence of a large hyphema, rupture from blunt trauma, or the need for exploration secondary to penetrating trauma.

References

Knoop, K. J., Knoop, K. J., & Stack, L. B. (n.d.). Chapter 2: Ophthalmic Conditions. In The Atlas of Emergency Medicine (p. 89). essay, McGraw-Hill Medical.
Pujari, A., Agarwal, D., Kumar Behera, A., Bhaskaran, K., & Sharma, N. (2019). Pathomechanism of iris sphincter tear. Medical hypotheses, 122, 147–149. https:// doi.org/10.1016/j.mehy.2018.11.013

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.