Page 107 - JSOM Winter 2024

Traumatic Hyphema with Commotio Retinae
in a Special Operations Environment

Scott R. Bird II, SO-ATP, NRP, FP-C *; Kaytlin E. Hack, MD, MC, FS ;
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John W. Kircher, MD ; Rachel E. Bridwell, MD, MC, FS 4
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ABSTRACT
Traumatic ocular injuries from both combat- and noncombat- history presented to the Role 2 (sick call with x-ray, ultra-
related activity remain a significant burden in active duty Ser- sound, laboratory, and surgical capabilities) with acute loss of
vicemembers and present a diagnostic and therapeutic chal- visual acuity and eye pain 20 minutes after being struck in
lenge to Special Operations medics with limited resources in the right eye (OD) with a rubber ball while playing American
far forward and remote areas. Blunt ocular injury, whether handball. The patient had not been wearing eye protection at
from sports or battlefield engagement, can result in a variety the time of injury and was not a contact lens wearer. The pa-
of eyesight-threatening injuries, including hyphema, commo- tient could only perceive lights and shadows and was unable
tio retinae, iritis, uveitis, and open globe injury. The manage- to differentiate objects in the right eye. He denied photopsia,
ment of these conditions often requires teleconsultation with scotoma, or a black curtain falling into his field of vision. The
ophthalmology and potential evacuation, which is tailored patient denied any other injury to the head and had not lost
to the resources available for the Special Operations Forces consciousness. There was no pain with eye movement, and he
medic. The authors present a case of sports-related traumatic reported no pain or changes in vision in his left eye (OS). The
hyphema complicated by commotio retinae in a Special Op- patient denied the use of alcohol, tobacco, or other substances.
erations unmanned aircraft systems (UAS) operator, requiring He reported no daily medications and no history of blood
teleconsultation and evacuation to specialty care. The authors thinning medications. The patient had no significant personal
additionally provide tailored prehospital strategies for the or family history of connective tissue disorders, hypertension,
management of these unique but imperative injuries. diabetes, cancer, glaucoma, sickle cell disease, hemoglobinopa-
thies, or macular degeneration.
Keywords: hyphema; commotio retinae; ophthalmology;
Special Operations Forces; SOF; Prolonged Casualty Care; Upon examination, the patient was alert and oriented to per-
PCC; teleconsultation; strategic evacuation; STRATEVAC son, place, time, and event, with unremarkable vital signs.
Vis ual acuity without correction was obtained using the
Snellen chart and was notable for OD hand motion vision
and OS 20/20. The patient’s head was normocephalic with
Introduction
no signs of obvious trauma, except for tenderness to palpa-
Sports-related injuries are the leading cause of hospitalization tion around the right orbit and ecchymosis along the nasoju-
and lost duty in the U.S. Military. In 2021, eye injuries ac- gal sulcus. The ocular exam included 3-mm pupils that were
1
counted for 8,609 diagnoses among active duty Servicemem- equal, round, and reactive to light and accommodation, with
bers at military treatment facilities, of which approximately extraocular movements intact. There was a right eye conjunc-
300 (4.5%) were deployment-associated encounters. Blunt tival injection and an approximately 15% anterior chamber
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traumatic ocular injury most commonly results in hyphema, hyphema with associated corneal cloudiness. No proptosis or
blood within the anterior chamber secondary to bleeding cho- appreciable periorbital swelling was noted. A fluorescein stain
roidal or iris circle arteries. Vision-threatening complications under Wood’s lamp revealed no corneal abrasions and a neg-
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from hyphema include secondary hemorrhage, corneal blood ative Seidel test.
staining, glaucoma, and anterior synechiae, though hyphema
may also be associated with commotio retinae or traumatic The patient was diagnosed with a grade 1 hyphema as demon-
retinopathy. The authors present an acute ocular injury of a strated by less than one-third of the anterior chamber being
4,5
Special Operations unmanned aircraft systems (UAS) operator filled with blood (Figure 1) and no signs of an open globe
in a deployed setting, demonstrating the use of telemedicine injury. He was advised to sit upright to avoid red blood cells
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for specialty consultation, which ultimately led to the strate- from staining the cornea. Ophthalmology at Landstuhl Re-
gic evacuation (STRATEVAC) of the U.S. Servicemember to gional Medical Center (LRMC) was consulted using the Global
Landstuhl Regional Medical Center (LRMC) for further mon- Teleconsult line. In addition to following the recommendations
itoring and care. of the Joint Trauma System Clinical Practice Guideline (JTS
CPG) on ocular trauma, including application of an eye shield
and bed rest with head elevation, ophthalmology also advised
Case Presentation
to begin treatment with the following eye drops: atropine 1%
While deployed, a 25-year-old male Special Operations UAS op- one drop OD daily for cycloplegia, prednisolone acetate 1%
erator, active duty Servicemember with no significant medical one drop OD four times daily for inflammation, and timolol
*Correspondence to scott.bird@socom.mil
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1 SSG Scott R. Bird II and CPT Rachel E. Bridwell are affiliated with Army Special Operations Aviation Command, Fort Bragg, NC. CPT Kaytlin
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E. Hack is affiliated with 1-19th Special Forces Group (Abn), 17800 Redwood Rd., Bluffdale, UT. MAJ John W. Kircher is affiliated with Land-
stuhl Regional Medical Center HQ Company, Unit 33100, APO AE 09180.
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