Page 108 - JSOM Winter 2024

one drop OD twice daily for the management of increased from permanent loss of receptors as well as retinal edema, vi-
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intraocular pressure (IOP). The patient was also prescribed sual acuity may improve as retinal edema resolves (Figure 2).
ondansetron 4mg oral dissolving tablets as needed for xnausea
to minimize elevation in IOP. The patient was accepted for pri- FIGURE 2 Hyphema grading system.
ority STRATEVAC to LRMC to be seen at the ophthalmology
clinic the next day by the consulting ophthalmologist. Prior to
the patient’s departure from the Role 2 and at approximately 8
hours after the injury, the patient reported some improvement
in vision in his right eye, specifically improvement of OD to
20/70 and the ability to read name tapes clearly on uniforms.
FIGURE 1 Grade 1 hyphema with 1/3 of the anterior chamber
pooled with blood. This was taken 30 minutes after the injury. Red
circle outline highlights the blood pooling in the anterior chamber.

(Courtesy of American Academy of Opthalmology.)

On evaluation on postinjury day 1, ophthalmology identified a
layering hyphema and commotio retinae but no globe rupture In addition to commotio retinae, other complications of trau-
or retinal tear or detachment. Visual acuity had normalized to matic hyphema include corneal bloodstaining leading to per-
20/20 in both eyes. IOP in the right eye was slightly elevated manent vision loss and elevated IOPs leading to central retinal
(21mmHg). The patient was instructed to keep his head ele- artery occlusion. Additionally, globe rupture can be seen in
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vated and to wear an eye shield. On postinjury day 4, IOP in nearly one-third of all hyphemas. Finally, elevations in the
his right eye had improved and returned to normal levels. On IOP can cause permanent damage to the optic nerve and must
postinjury day 12, the patient was reevaluated, his medication be monitored regularly by an ocular professional to avoid vi-
regimen tapered, and he was cleared to return to his home sion loss.
station to resume normal activity and flight status.
Diagnosing and treating this type of injury is well within the
Special Operations Forces (SOF) medic’s scope of practice, but
Discussion
certain considerations must be made given the various limita-
This case combines medical complexity with logistical chal- tions of medical supplies and equipment. In austere environ-
lenges in a deployed setting. Traumatic hyphema is the accu- ments, SOF medics must strategize for the medical assessment
mulation of blood in the anterior chamber of the eye due to and treatment, employing the Prolonged Casualty Care par-
blunt force or penetrating injury to the vessels of the ciliary adigm known as “Ruck, Truck, House, Plane.” This tiered
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body or iris. Systemic conditions such as hemoglobinopathies approach involves escalating levels of medical resources (from
(e.g., sickle cell disease and thalassemia) or the use of anticoag- those carried by the medic, to those available in a vehicle, to
ulants can increase the risk of elevated IOP or rebleeding. The prestaged medical resources in a safehouse, and finally to evac-
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severity of a hyphema is graded by assessing the height of the uation toward definitive care). This approach ensures optimal
layering blood relative to the anterior chamber. Grade 1 is less and comprehensive care is given to a patient regardless of the
than one-third of the anterior chamber, grade 2 is one-third to various limitations in tactical situations.
one-half of the anterior chamber, grade 3 is greater than half
of the anterior chamber, and grade 4 is complete filling of the Ruck
anterior chamber with blood, also known as the “eight ball” Gently fluorescein stain the eye and evaluate with an ultraviolet
hyphema. Patients often complain of loss of visual acuity due light for evidence of open globe injury including Seidel’s sign.
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to direct obstruction from the blood, but approximately 26% Apply an eye shield and advise the patient to elevate the head
of hyphema patients have concomitant commotio retinae that to a minimum of 45°. This helps prevent the accumulation of
can also impact visual acuity. Commotio retinae is a phe- red blood cells, which could potentially stain the cornea, and
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nomenon of direct or indirect injury to the globe, causing a reduces the risk of increased IOP caused by acute angle closure
contrecoup injury to the retina as shockwaves cause retinal of the trabecular meshwork, thus promoting optimal drainage
disruption. Early evaluation by dilated eye exam can reveal of the aqueous humor. Provide analgesia with topical tetracaine
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opacification of the retina indicative of disrupted photorecep- eye drops (which provide approximately 45 minutes of pain re-
tor cells seen in commotio retinae. While visual loss may result lief), acetaminophen, or a non-NSAID pain reliever to minimize
106 | JSOM Volume 24, Edition 4 / Winter 2024