A 20-year-old man presents to urgent care after sustaining a blow to his left eye during an altercation. He reports immediate pain and decreased vision in the eye. He denies loss of consciousness, headache, or other injuries. On gross inspection of the eye, you see blood accumulated in the anterior chamber and suspect traumatic hyphema. His pupils are equal, round, and reactive to light, and his extraocular movements are intact but limited by pain. There does not appear to be any evidence of orbital fracture, proptosis, or gross globe laceration.
What is the next best step in the management of this patient?
- Diagnose an open-globe injury, then immediately refer to the emergency department for surgical repair.
- Assess the patient’s intraocular pressure, provide pain control, and protect the injured eye with a rigid eye shield before referring the patient urgently to the emergency department.
- Provide a nonsteroidal anti-inflammatory drug for pain and discharge.
- Provide aspirin for pain and discharge the patient with instructions to follow-up with an ophthalmologist within 3 days.
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Answer: b. Assess the patient’s intraocular pressure, provide pain control, and protect the injured eye with a rigid eye shield before referring the patient urgently to the emergency department.
You conducted a careful and thorough physical examination to look for signs of open-globe injury and orbital compartment syndrome, which must be ruled out prior to initiating treatment. Your focused examination revealed no visible corneal or scleral laceration and no irregular pupil. In addition, the patient did not appear to have signs of orbital compartment syndrome such as proptosis and his intraocular pressure was not elevated on tonometry (ie, above >40 mmHg).
The presence of blood in the anterior chamber after blunt trauma is suggestive of traumatic hyphema. It is a potentially serious condition because it can lead to complications and permanent vision loss if not treated promptly. Given the vision loss and presence of hyphema, your patient required urgent evaluation by an ophthalmologist in the emergency department. You positioned him upright, so his head was elevated at least 45˚to promote settling of blood, applied a rigid eye shield to protect his left eye without pressure, and provided acetaminophen for pain control. NSAIDs and aspirin should be avoided due to increased risk of rebleeding. You continued to monitor for complications and asked the patient about any underlying conditions that could alter his ED management while waiting for EMS to arrive.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
