What is the initial management for a patient with blunt eye trauma, considering potential pre-existing conditions such as glaucoma or bleeding disorders?

Initial Management of Blunt Eye Trauma

Immediately assess visual acuity, pupillary response, intraocular pressure (IOP), and perform detailed slit-lamp biomicroscopy and ophthalmoscopy to identify vision-threatening injuries including hyphema, lens dislocation, angle recession, and retinal pathology. 1

Immediate Assessment Protocol

Primary Survey (First 15 Minutes)

• Measure visual acuity as the single most important prognostic indicator—document even if only light perception or hand motion 1
• Evaluate pupillary responses for relative afferent pupillary defect (RAPD), which indicates optic nerve or severe retinal injury 1
• Assess extraocular motility to detect orbital fractures, muscle entrapment, or nerve damage 1
• Measure intraocular pressure immediately, as both elevated IOP (from hyphema, angle damage, lens injury) and hypotony (from occult rupture) are vision-threatening 1, 2

Critical Examination Components

• Perform slit-lamp biomicroscopy to identify hyphema grade, iris tears, lens subluxation/dislocation, vitreous prolapse, and angle recession 1, 3
• Conduct dilated fundoscopy (if no contraindication from hyphema or suspected rupture) to detect retinal tears, detachment, choroidal rupture, or vitreous hemorrhage 1, 4
• Examine the fellow eye extensively—less obvious trauma to the contralateral eye can harbor serious injuries in the angle or peripheral retina 4

High-Risk Injury Patterns Requiring Urgent Intervention

Pattern Recognition for Immediate Ophthalmology Consultation

• Hyphema grade II-IV with iris-lens injury and vitreous hemorrhage carries high rebleeding risk and requires hospitalization with head elevation, cycloplegia, and IOP monitoring 3
• Angle recession >180 degrees predicts secondary open-angle glaucoma development and requires lifelong surveillance 3
• Vitreous prolapse with lens dislocation indicates high risk for retinal detachment requiring urgent vitreoretinal surgery 3, 5

Vision-Threatening Conditions Requiring Same-Day Treatment

• Penetrating wounds require immediate surgical exploration and repair 1
• Traumatic hyphema with elevated IOP >30 mmHg requires urgent medical management (topical beta-blockers, alpha-agonists, carbonic anhydrase inhibitors) or surgical evacuation if refractory 2
• Retinal detachment requires urgent vitreoretinal surgery within 24-48 hours to prevent permanent vision loss 1, 5

Management of Pre-existing Conditions

Patients with Glaucoma

• Monitor IOP more aggressively—traumatic IOP elevation superimposed on pre-existing glaucoma accelerates optic nerve damage 2
• Angle recession in glaucoma patients has higher risk of immediate and delayed IOP spikes requiring more intensive medical therapy 2
• Continue baseline glaucoma medications unless contraindicated by specific injury pattern 2

Patients with Bleeding Disorders or Anticoagulation

• Do NOT routinely reverse anticoagulation unless massive intraocular hemorrhage threatens vision or requires urgent surgery 6
• For vitamin K antagonist users with severe hyphema requiring surgery, consider prothrombin complex concentrate (PCC) per manufacturer instructions only if PT >1.5 times normal 6
• Avoid antifibrinolytic agents (tranexamic acid) in isolated eye trauma—these are indicated only for systemic hemorrhagic shock, not ocular bleeding 6
• Higher rebleeding risk in hyphema patients on anticoagulation requires more intensive monitoring with daily IOP checks and anterior chamber assessment 3

Critical Pitfalls to Avoid

• Never assume a normal initial examination excludes serious injury—vitreous hemorrhage may obscure retinal tears, and angle damage may not manifest elevated IOP for weeks to years 4, 3
• Never perform tonometry on suspected globe rupture—look for 360-degree subconjunctival hemorrhage, peaked pupil, shallow anterior chamber, or hypotony as warning signs 1
• Never dilate pupils before ruling out angle-closure risk in patients with lens subluxation or pupillary block from hyphema 2
• Never discharge patients with hyphema without arranging next-day follow-up—rebleeding peaks at 3-5 days and can cause irreversible glaucoma 3

Disposition and Follow-up

• Admit patients with hyphema grade II-IV, elevated IOP >30 mmHg, or suspected occult rupture for continuous monitoring 3
• Arrange ophthalmology follow-up within 24 hours for all blunt trauma patients, even with seemingly minor findings 1, 4
• Schedule long-term surveillance for angle recession, traumatic cataract progression, and delayed retinal detachment—complications can manifest months to years after injury 4, 3