Differential Diagnosis for Facial Trauma and Eye Symptoms

The patient's symptoms, including a painful right eye, smaller pupil, circumcorneal hyperemia, and photophobia, following a direct spike to the face during volleyball, suggest several potential diagnoses. These can be categorized as follows:

• Single Most Likely Diagnosis

  • Hyphema with possible traumatic iritis: The direct trauma to the face could have caused bleeding into the anterior chamber of the eye (hyphema), which, along with the symptoms of pain, smaller pupil (miosis), circumcorneal injection (hyperemia), and photophobia, points towards an inflammatory response within the eye, possibly due to traumatic iritis. The smaller pupil could also be indicative of irritation of the uveal tract.

• Other Likely Diagnoses

  • Corneal abrasion or laceration: Direct trauma could result in a scratch or cut on the cornea, leading to pain, photophobia, and possibly a smaller pupil due to irritation.
  • Orbital fracture: Although not directly causing the eye symptoms, an orbital fracture could be associated with other facial injuries from the trauma and might indirectly affect eye movement or cause enophthalmos, though this wouldn't directly explain the smaller pupil or photophobia.
  • Traumatic mydriasis or miosis: Depending on the nature of the injury, the pupil could be affected, but the combination with other symptoms like photophobia and hyperemia makes hyphema or iritis more likely.

• Do Not Miss Diagnoses

  • Ruptured globe: This is a medical emergency that requires immediate attention. Symptoms can include severe pain, vision loss, a teardrop-shaped pupil, and possibly a soft eye. Although the patient's symptoms don't directly point to this, any significant trauma to the eye warrants a thorough examination to rule out a globe rupture.
  • Retinal detachment: Trauma can cause retinal detachment, which might not immediately present with the described symptoms but could lead to severe vision loss if not promptly treated.
  • Intraocular foreign body: If the object that caused the trauma was sharp or penetrated the eye, there could be a foreign body inside the eye, which is an emergency requiring immediate surgical intervention.

• Rare Diagnoses

  • Sympathetic ophthalmia: A rare, bilateral granulomatous uveitis that can occur after penetrating eye injury. It's a delayed reaction and would not immediately follow the trauma but is a potential long-term complication.
  • Angle recession glaucoma: This can occur weeks to months after the initial trauma due to scarring and closure of the trabecular meshwork, leading to increased intraocular pressure. It's a rare but significant complication of blunt ocular trauma.