What is the recommended management and examination for a patient presenting with blunt eye trauma and red eye?

Eye Examination for Blunt Eye Trauma with Red Eye

In patients presenting with blunt eye trauma and red eye, perform immediate visual acuity testing, pupillary examination, intraocular pressure measurement, slit-lamp biomicroscopy, and dilated fundoscopy to identify vision-threatening injuries including hyphema, globe rupture, angle recession, lens dislocation, retinal tears, and traumatic optic neuropathy. 1, 2

Critical Initial Assessment Components

Immediate Examination Priorities

• Visual acuity measurement is the first essential step, as it establishes baseline vision and helps stratify injury severity 1, 2
• Pupillary examination must assess for relative afferent pupillary defect (RAPD), which indicates optic nerve damage or severe retinal injury, and evaluate pupil shape/position suggesting iris trauma 3, 2
• Intraocular pressure (IOP) measurement is mandatory to detect elevated pressure from angle damage or hypotony from occult globe rupture 1, 2
• Extraocular motility testing identifies orbital fractures with muscle entrapment, cranial nerve injury, or direct muscle damage 1, 4

Systematic Slit-Lamp Biomicroscopy

The anterior segment examination must systematically evaluate 2, 5:

• Conjunctiva and sclera: Look for subconjunctival hemorrhage, which may hide underlying scleral rupture, and carefully inspect for full-thickness lacerations
• Cornea: Assess for abrasions, edema, and foreign bodies using fluorescein staining
• Anterior chamber: Grade hyphema (blood layering), assess depth, and look for cells/flare indicating traumatic iritis 5
• Iris: Document tears, iridodialysis (root detachment), traumatic mydriasis, or irregular pupil shape 5
• Lens: Evaluate for subluxation, dislocation, traumatic cataract, or phacodonesis (wobbling) 5

Critical pitfall: Hyphema grade II-IV (>1/3 anterior chamber filled with blood) carries high risk of rebleeding within 3-5 days and requires close ophthalmologic monitoring 5

Dilated Fundoscopic Examination

Posterior Segment Evaluation

After ruling out globe rupture, perform dilated examination using 3, 6:

• Indirect ophthalmoscopy to visualize the far peripheral retina where traumatic tears commonly occur 3, 6
• Slit-lamp biomicroscopy with appropriate lenses for detailed posterior pole and mid-peripheral retinal assessment 3
• Vitreous examination for hemorrhage, pigment cells (Shafer's sign indicating retinal tear), or prolapse 5

Specific Findings to Document

Look for vision-threatening posterior injuries 6, 2:

• Retinal tears or detachment: Particularly in the far periphery where blunt trauma causes vitreoretinal traction
• Choroidal rupture: Crescent-shaped breaks in Bruch's membrane, often concentric to the optic disc
• Commotio retinae (Berlin's edema): Retinal whitening from photoreceptor disruption, especially threatening when involving the macula
• Traumatic optic neuropathy: Optic disc edema, hemorrhage, or pallor with associated RAPD
• Vitreous or preretinal hemorrhage: May obscure underlying retinal pathology requiring serial examinations 3

Gonioscopy for Angle Assessment

Gonioscopy should be performed once hyphema resolves or is minimal to evaluate for angle recession, which occurs in up to 94% of eyes with hyphema and predisposes to late-onset glaucoma 3, 5

• Angle recession >180 degrees significantly increases risk of secondary open-angle glaucoma requiring lifelong monitoring 5

Imaging Considerations

Non-contrast thin-section orbital CT with multiplanar reconstructions is the imaging modality of choice when globe rupture, intraocular foreign body, or orbital fracture is suspected 1

• CT is superior for identifying orbital fractures and displaced bone fragments 1
• MRI is contraindicated if metallic foreign body is suspected 1

Management Algorithm Based on Findings

Immediate Ophthalmology Consultation Required

Urgent referral is mandatory for 1, 2, 7:

• Globe rupture (positive Seidel test, shallow anterior chamber, irregular pupil, uveal prolapse)
• Hyphema grade II-IV (>1/3 chamber involvement)
• Lens dislocation with vitreous prolapse
• Retinal detachment or large retinal tears
• Traumatic optic neuropathy with vision loss and RAPD
• Orbital compartment syndrome (proptosis, elevated IOP, vision loss)

Observation and Follow-up

Patients with minor injuries require serial examinations because 6, 2:

• Delayed complications including angle recession glaucoma, traumatic cataract, and retinal detachment may develop weeks to years after injury
• Both eyes must be examined even when one appears more severely injured, as bilateral trauma is common 6
• Peripheral retinal tears may be missed initially and require repeat dilated examination once media clears 6

Common Pitfalls to Avoid

• Missing occult globe rupture hidden by subconjunctival hemorrhage—avoid pressure on the globe and obtain CT if suspected 1, 2
• Failing to examine the fellow eye thoroughly, as bilateral injuries are frequently present 6
• Discharging patients with significant hyphema without ophthalmology follow-up within 24 hours due to rebleeding risk 5
• Overlooking angle recession by not performing gonioscopy after hyphema resolution, missing patients at risk for late glaucoma 5
• Attributing red eye to simple subconjunctival hemorrhage without ruling out more serious underlying injuries through complete examination 2, 7