What is the management for a conjunctival hemorrhage with an undetermined posterior border after trauma from mowing the lawn?

Management of Conjunctival Hemorrhage with Undetermined Posterior Border Following Lawn Mowing Trauma

A conjunctival hemorrhage with an undetermined posterior border following lawn mowing trauma requires urgent ophthalmologic evaluation to rule out globe penetration or serious ocular injury.

Initial Assessment

• Assess for signs of globe penetration or rupture:

  • Visual acuity testing
  • Pupillary assessment for relative afferent pupillary defect
  • Confrontation visual field examination
  • Examination for vitreous hemorrhage, detachment, or pigmented cells 1

• Evaluate the extent of hemorrhage:

  • Document size, location, and borders of hemorrhage
  • Inability to visualize the posterior border raises concern for posterior extension

• Check for associated injuries:

  • Foreign bodies (common with lawn mower injuries)
  • Corneal abrasions or lacerations
  • Eyelid lacerations

Diagnostic Approach

• Perform slit-lamp examination with fluorescein staining to identify corneal injuries
• Conduct dilated fundus examination using indirect ophthalmoscopy with scleral depression to evaluate the peripheral retina 1
• If media opacity precludes adequate examination of the peripheral retina, B-scan ultrasonography should be performed to search for retinal tears or detachment 1
• Consider optical coherence tomography to evaluate for subtle injuries

Management Algorithm

1. For simple subconjunctival hemorrhage without posterior extension:

   • Reassurance (most resolve spontaneously within 2-3 weeks)
   • Artificial tears for comfort
   • Cold compresses for the first 24-48 hours
   • Avoid blood thinners if possible

2. For hemorrhage with undetermined posterior border:

   • Urgent ophthalmologic consultation
   • Apply topical hemostyptics and continue local compression 2
   • Monitor vital signs and hemoglobin levels 2
   • Dilated fundus examination to rule out posterior segment involvement
   • B-scan ultrasonography if view is obscured

3. If signs of globe penetration or serious injury are present:

   • Immediate ophthalmologic intervention
   • Protect the eye with a rigid shield (no pressure)
   • No topical medications until evaluated by ophthalmologist
   • NPO status in case surgical intervention is needed

Follow-up Care

• For simple subconjunctival hemorrhage:

  • Follow-up in 1-2 weeks
  • Earlier follow-up if symptoms worsen

• For hemorrhage with undetermined posterior border:

  • Close follow-up (every 1-2 weeks initially) until hemorrhage resolves and posterior segment can be fully evaluated 1
  • Monitor for signs of infection or delayed complications

Special Considerations

• Lawn mower injuries are a significant cause of serious visual impairment and may involve intraocular foreign bodies 3
• The inability to determine the posterior border of a conjunctival hemorrhage should raise suspicion for more serious injury
• Blood in the anterior vitreous (Schafer's sign) indicates globe penetration and requires immediate surgical intervention
• Wide-field color photography may be helpful but does not replace careful ophthalmoscopy 1

Prevention of Future Injuries

• Advise proper eye protection during lawn mowing activities
• Educate about clearing the lawn of potential projectiles before mowing
• Discuss proper lawn mower maintenance and safety features

Lawn mower eye injuries are preventable with proper eye protection, yet they remain a significant cause of visual impairment 3. The inability to visualize the posterior border of a conjunctival hemorrhage following trauma warrants thorough evaluation to rule out serious ocular injury that could threaten vision.