|Year : 2014 | Volume
| Issue : 1 | Page : 52-54
Reversible blindness following squash ball injury
Avinash Mishra1, Vinod Kumar Baranwal2, Vinod Kumar Patra3, Neeraj Bhargava4
1 Classified Specialist (Ophthalmology) Military Hospital, Ahmedabad, Gujarat, India
2 Senior Advisor (Ophthalmology), Command Hospital (NC),Udhampur, India
3 Senior Advisor (Ophthalmology), Military Hospital, Secunderabad, Andhra Pradesh, India
4 Senior Advisor (Ophthalmology), Command Hospital (SC), Pune, Maharashtra, India
|Date of Web Publication||26-Aug-2014|
Classified Specialist (Ophthalmology), Military Hospital, Ahemdabad Cant, Hanuman Camp, Shahibag, Ahemdabad - 380 004, Gujarat
Source of Support: None, Conflict of Interest: None
Hyphema is the presence of red blood cells in the anterior chamber and is the most common mode of clinical presentation, after significant ocular trauma. Traumatic hyphema is an opthalmic emergency and its treatment is generally medical; however, occurrence of secondary hemorrhage may necessitate surgical intervention. Though hyphema is of such a common occurrence there is still a lack of agreement about its management protocols basically involving medical management versus an early surgical intervention. Controversy also exists regarding the various strategies to be adopted to prevent rebleeding.Here, we report an interesting case of a young patient who developed total hyphema, following a squash ball injury. He was initially managed conservatively but suffered rebleeding into the anterior chamber along with its associated complications and finally required an active surgical intervention. He showed a remarkable postsurgical improvement and was finally discharged with a normal visual acuity of 6/6 in both eyes.
Keywords: Hyphema, intraocular pressure, ocular trauma
|How to cite this article:|
Mishra A, Baranwal VK, Patra VK, Bhargava N. Reversible blindness following squash ball injury. Afr J Trauma 2014;3:52-4
| Introduction|| |
Hyphema is the presence of red blood cells in the anterior chamber. ,, It is the most common mode of clinical presentation after significant blunt or lacerating ocular trauma, occurring in 81% of the eyes in one study.  Hyphema is best classified according to the amount of red blood cells in the anterior chamber  and graded according to the level of the blood layer present [Table 1].  Traumatic hyphema is an ophthalmic emergency. Treatment of hyphema is generally medical and in many mild cases it resolves without any residual adverse effects. However, occurrence of secondary hemorrhage is often associated with several serious complications like secondary glaucoma and corneal staining. 
Though hyphema is of such a common occurrence there is still a lack of agreement about its management protocols. Medical management is usually the recommended protocol; however, in some cases, an early surgical intervention may be beneficial. If surgery is to be performed, then its timing as well as the type of surgery to be carried out is also controversial. There is also a lot of debate regarding the various strategies to be adopted to prevent a rebleeding.
| Case Report|| |
A 27-year-old patient was transferred to this center from a peripheral hospital, with history of squash ball injury to his right eye, sustained about 6 h back. There was no history of diabetic, liver, or renal disease. Ocular examination on presentation revealed a visual acuity (VA) of hand movements close to face, severe circumciliary congestion, an extremely hazy cornea and total hyphema precluding further visualization of the eye. The intraocular pressure (IOP) was 54 mm Hg as measured using a noncontact tonometer (NCT). The left eye examination was essentially normal with a VA of 6/6 and an IOP of 14 mm Hg NCT. A complete blood count, differential count, platelet count, bleeding, and clotting time were essentially normal. Sickle cell anemia as well as the other abnormal hemoglobinopathies too were investigated for, but they too were negative.
Treatment was then started with intravenous 20% mannitol, 300 mL given stat over 30 min, followed by oral acetazolamide tablets, 500 mg 8 hourly for the next 3 days, to reduce the raised IOP. Ideally, genotyping should have been carried out prior to starting treatment with oral acetazolamide; however, its facilities were not available at our centre. Topical antiglaucoma medication, that is, eye drop timolol maleate 0.5%, 12 hourly and eye drop brimonidine tartrate 0.15%, 12 hourly along with a cycloplegic, that is, eye drop homatropine hydrobromide 2.0%, 6 hourly were also started. Topical and systemic steroids in high doses (eye drop prednisolone acetate, 1 hourly as well as oral prednisolone 60 mg once daily (OD) were started from the 2 nd day onward. These were gradually tapered off over the next 4 weeks, that is, reducing the oral prednisolone by 10 mg every 3 rd day. The patient was given an eye shield and advised a restriction in his physical activity. Initially, within the first 48 h, the patient showed a mild improvement. The ocular pain reduced and his IOP too reduced marginally, to 42 mm Hg NCT. However the hyphema showed very little resolution, and rather after 72 h even appeared to have even increased, along with a further rise in IOP to 68 mm Hg NCT.
The patient too complained of an increased ocular pain, along with a throbbing right sided headache. Rebleeding into the anterior chamber was suspected and patient had surgery on the 3 rd day postinjury. This was done to prevent any corneal blood staining from developing in the setting of a raised IOP. Just prior to the surgery, intravenous 20% mannitol, 300 mL over 20 min was given to lower the IOP. A thorough irrigation and aspiration of the anterior chamber was performed under local anesthesia and the blood clot was completely aspirated out.
Postoperatively, the patient showed a remarkable improvement with the first postoperative day VA improving to 6/60 on the Snellen's chart and the IOP reducing to 36 mm Hg NCT. The VA gradually improved over the next 3 weeks and became normal, that is, 6/6 at the end of 3 weeks.
Detailed fundoscopy was possible only 2 weeks postsurgery and it revealed no obvious retinal damage.
The antiglaucoma medications as well as the cycloplegics were gradually tapered off over a period of 4 weeks.
The patient was finally discharged 4 weeks postsurgery, with a normal VA of 6/6 in both eyes and an IOP of 13 mm Hg and 14 mm Hg in his right and left eye, respectively, though both the parameters are being regularly followed-up on a monthly outpatient basis. Gonioscopy performed 2 months after the surgery too revealed a normal anterior chamber angle with no signs of any angle recession.
His condition has since remained stable till the last follow-up, done nearly a year postinjury.
| Discussion|| |
There is a considerable diversity of opinion among the ophthalmologists concerning the management of acute traumatic hyphema. In our case, we had initially managed the patient with systemic as well as topical antiglaucoma drugs as he had presented with a very high IOP. We also treated our patient with topical mydriatics, though their effect on preventing re bleeding is controversial. However, we routinely use mydriatics in the treatment of traumatic hyphaema as it relieves ciliary spasm and pain. , It also allows an early fundus examination. We also recommend the use of steroids both topical as well as systemic, from the second day onward as they are useful in decreasing the associated iridocyclitis and also in preventing the development of peripheral anterior or posterior synechiae. Studies have also shown that steroids play a role comparable to antifibrolytics in preventing rebleeding, , The use of antifibrinolytics has been advocated by several authors with the assumption that rebleeding occurs as a result of fibrinolysis of the clot. Clot lysis and retraction occur 2-5 days after the injury, and the risk of rebleeding from the injured vessels is maximum at this time.  Though studies have reported re-bleeding to occur in 0.4%-35% of patients with hyphema; ,, however, we do not routinely use antifibrolytics, as in our experience rebleeding is relatively rare among our patients. A similar finding has also been found in other studies too. , In addition use of systemic antifibrolytics is associated with various side effects like nausea, vomiting diarrhea, and postural hypotension. Termination of antifibrolytic therapy before completion of its 5 days course may also result in a greater tendency to rebleed.
General measures like hospitalization, bed rest, eye shield application, and avoidance of strenuous activity are the same as supported by most of the literature. ,,
We subjected our patient to surgery within 72 h of the trauma, as his IOP was not being controlled medically. In such a setting there are always chances of optic nerve damage as well as corneal blood staining.  This usefulness of an early surgery has been confirmed by several other large scale studies. , Though there is still a lot of debate as to the exact timing of surgery, with one large scale study suggesting a range of indications varying from IOP level of 35 mm Hg for 2 days to 55 mm Hg for 14 days.  Surgery being relatively safe, we feel that it should be performed early in cases of total hyphema, unless the elevated IOP is adequately controlled medically and spontaneous resolution is clearly imminent. Various surgical techniques have been advocated regarding hyphema treatment including paracentesis, anterior chamber washout, expression of clot, automated removal of the blood, and trabeculectomy. , All these procedures are quite effective and the type of surgery performed should be tailored according to the patient's individual requirements.
These patients should also be regularly followed-up on an outpatient basis, as a significant number of patients with history of blunt ocular injury and hyphema have been known to develop chronic glaucoma later in life.
Hyphema in patients who have sickle cell disease or who are carriers of sickle cell traits may even occur spontaneously and presents unusual management difficulties. Even a small amount of blood in the anterior chamber may cause markedly elevated IOP. , They are also more prone to develop infarctions of the optic nerve, retina, and anterior segment. Medical and surgical therapy needs to be more aggressive in these patients and early surgical intervention is indicated even with a moderately elevated IOP.
| Conclusion|| |
The incidence of ocular injuries in sports is rising and is a matter of great concern. These injuries are especially significant as a large majority of them occur in children and young healthy adults. Also, significant is the fact that most of these injuries are considered preventable. Simple measures such as health education regarding the use of protective eyewear will play a major role in drastically decreasing this preventable cause of visual disability.
Glaucoma is one of the leading complications of traumatic hyphaemas. Surgery being a relatively safe and effective alternative in these patients; the authors recommend an early surgical intervention in those cases of traumatic hyphema which are associated with medically uncontrolled glaucoma.
| Acknowledgment|| |
The authors acknowledge the help provided by our clinical colleagues as well as the entire surgical staff.
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