injuries poisoning
Eye Contusions and Lacerations
Hyphema (anterior chamber hemorrhage)
Hyphema may be followed by recurrent bleeding, intraocular pressure (IOP) abnormalities, and/or blood staining of the cornea, any of which may result in permanent vision loss. Symptoms are of associated injuries unless the hyphema is large enough to obstruct vision. Direct inspection typically reveals layering of blood or the presence of clot or both in the anterior chamber. Layering is seen as a meniscus-like blood level in the dependent (usually inferior) part of the anterior chamber. Microhyphema, a less severe form, may be detectable by direct inspection as haziness in the anterior chamber by Slit-lamp examination with visualization of suspended red blood cells. An ophthalmologist should attend to the patient as soon as possible. The patient is placed on bed rest with the head elevated 30 to 45° and is given an eye shield to protect the eye from further trauma (see Corneal Abrasions and Foreign Bodies ). Patients who are at high risk of recurrent bleeding (eg, those with large hyphemas, bleeding diatheses, anticoagulant use, or sickle cell disease), who have IOP that is difficult to control, or who are likely to be nonadherent to recommended treatment may be hospitalized. Testing for bleeding abnormalities should be considered if the cause of the hyphema is not known. Oral and topical nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated because they may contribute to recurrent bleeding. IOP can rise acutely (within hours, usually in patients with sickle cell disease or trait) or months to years later. Thus, IOP is monitored daily for several days and then regularly over subsequent weeks and months and if symptoms develop (eg, eye ache, decreased vision, nausea—similar to symptoms of acute angle-closure glaucoma). If pressure rises,timolol0.5% twice a day,brimonidine0.2% or 0.15% twice a day, or both are given. Response to treatment is determined by pressure, often checked every 1 or 2 hours until controlled or until a significant rate of reduction is demonstrated; thereafter, it is usually checked once or twice daily. Mydriatic drops (eg,scopolamine0.25% 3 times a day oratropine1% 3 times a day for 5 days) and topical corticosteroids (eg,prednisoloneacetate 1% 4 to 8 times a day for 2 to 3 weeks) are often given to reduce inflammation and scarring. If bleeding is recurrent, an ophthalmologist should be consulted for management. Administration ofaminocaproic acid50 to 100 mg/kg orally every 4 hours (not exceeding 30 g/day) for 5 days or transexamic acid 25 mg/kg orally administered 3 times daily for 5 to 7 days may reduce recurrent bleeding, and miotic or mydriatic drugs must also be given. Rarely, recurrent bleeding with secondary glaucoma requires surgical evacuation of the blood. 