©2017 American Academy of Ophthalmology, reprinted with permission.

Hyphema can lead to increased IOP and corneal blood staining. This is graded on the amount of blood in the anterior chamber. The risk of IOP elevation increases with the grade of the hyphema (Figure 8).11

- Grade 0: no visible blood layering
- Grade 1: blood fills less than one-third of anterior chamber
- Grade 2: blood fills one-third to one-half of anterior chamber
- Grade 3: blood fills one-half to less than total anterior chamber
- Grade 4: blood fills entire anterior chamber

Goal

Identify significant ocular injuries; protect the eye from further injury.

Minimum

- Obtain and record visual acuity and critical injury details (e.g., mechanism of injury, presence of eye protection).
- Protect the injured globe and prevent further damage with a rigid shield.
- Raise the head 30°–45°; this allows any free-floating blood in the anterior chamber to settle away from the pupil and prevent pupillary block (which can lead to angle closure and elevated IOP).11
- Initiate pain control as needed; avoid nonsteroidal anti-inflammatory drugs, because of risk of worsening intraocular bleeding.
- Prevent further injury with antiemetics (ondansetron 4mg ODT/IV/IO/IM every 8 hours as needed).
- Activate evacuation with goal of evaluation by an eye surgeon within 24 hours.

Initiate teleconsultation with photographs.

Best

- Initiate a detailed ocular evaluation to direct treatment.
- Hyphema (anterior chamber injury)11
- Topical corticosteroid drop (prednisolone acetate 1%) 4 times per day
- Cycloplegic eye drop (cyclopentolate 1%), 1 drop every 8 hours
- Monitor for rebleeding when the clot in anterior chamber retracts, usually at 3–5 days after injury.
- This may result in vision change and increased size of hyphema.12
- If there is evidence of further bleeding or increasing IOP, initiate medications to decrease IOP:
  - Timolol 0.5%, 1 drop twice a day in affected eye
  - Acetazolamide 500mg PO initial dose, followed by 250mg PO 4 times per day (Note: contraindicated in patients with sickle cell trait) or 3% hypertonic saline 250mL IV or mannitol: 1g/kg IV over 30–60 minutes.

NOTE: Tranexamic acid for prevention of rebleeding in hyphema has not shown any benefit 13 but may be used in multitrauma patients if otherwise indicated.

Posterior chamber injury: Injuries to the retina and optic nerve as a result of blunt injury will result in vision loss. Findings may include decreased visual acuity, vision loss, loss of red reflex through the pupil, positive RAPD, or evidence of vitreous hemorrhage or retinal detachment on ultrasound evaluation.

- Initiate supplemental oxygen as available if suspicious for retinal detachment (e.g., cut in visual field, decreased vision, positive RAPD); this may improve visual outcome.14
- If no evidence of OGI, perform careful ultrasound to evaluate vitreous and retina, if available/trained. Transmit ultrasound images with telemedicine consultation to an eye specialist.

Initiate real-time video telemedicine consultation.

- No altitude restrictions are required for blunt/closed globe injury.

4. EYELID LACERATION

Lid lacerations can result from either sharp or blunt trauma (Figures 9–11). As with other injuries, the primary concern with lid injuries is the possibility of underlying globe injury. Lid lacerations have a low incidence of infection (unless the causative factor is an animal or human bite). Any avulsed tissue should be preserved in saline and chilled, whenever possible, and sent with the patient—not discarded or debrided. Meticulous closure of eyelid structures with proper magnification is usually required to maintain lid function. If fat is visible in an eyelid laceration, this indicates violation of the orbital septum, a key anatomic barrier to infection. If prolapsed orbital fat is identified, appropriate antibiotic coverage is needed as well as expedited evacuation for surgical exploration and repair. Do not attempt to excise or suture exposed orbital tissue; this can lead to uncontrolled bleeding in the orbit.