What are the differential diagnoses for a 15-year-old male who sustained a basketball-related eye injury with rapid swelling, bruising, and blurred vision?

Differential Diagnoses for Basketball-Related Eye Injury with Swelling, Bruising, and Blurred Vision

In a 15-year-old male with basketball-related eye trauma presenting with rapid swelling, bruising, and blurred vision, the primary differential diagnoses include orbital floor fracture with or without muscle entrapment, hyphema, globe rupture/laceration, traumatic optic neuropathy, and retrobulbar hemorrhage. 1, 2, 3

Critical Life- and Vision-Threatening Conditions to Exclude First

Globe Rupture/Open Globe Injury

• Globe injury occurs in up to 24% of orbital fractures and must be excluded immediately as it represents the most vision-threatening diagnosis 3
• Look for active bleeding from the eye (hard sign of penetrating injury), irregular pupil, visible uveal tissue, or severe subconjunctival hemorrhage obscuring the sclera 4
• If suspected, protect the eye with a rigid shield without applying pressure and obtain immediate ophthalmology consultation before any imaging 4
• Do not perform forced duction testing if open globe is possible 4

Retrobulbar Hemorrhage

• Presents with rapidly progressive proptosis, severe pain, decreased vision, and elevated intraocular pressure 5, 6
• This is an ophthalmologic emergency requiring immediate lateral canthotomy if diagnosed 5, 6
• Check for afferent pupillary defect and measure intraocular pressure 4

Traumatic Optic Neuropathy

• Manifests as visual loss, visual field defects, or afferent pupillary defect 1, 3
• Can occur even without obvious external injury 1

High-Probability Diagnoses in This Clinical Scenario

Orbital Floor Fracture (Most Common in This Age Group and Mechanism)

• Orbital floor fractures are the most common isolated facial fracture in older children and adults, with motor vehicle collisions and sports injuries being leading causes 3
• Clinical signs include periorbital soft tissue swelling, ecchymosis, subconjunctival hemorrhage, and restriction of ocular movement 2
• Diplopia on upward gaze specifically suggests inferior rectus muscle or orbital tissue entrapment in an orbital floor fracture 2
• Monitor vital signs for bradycardia or heart block—this indicates oculocardiac reflex from muscle entrapment, which is potentially life-threatening and requires urgent surgical intervention 2, 3, 4

Hyphema (Blood in Anterior Chamber)

• Common with blunt ocular trauma from sports injuries 4, 5
• Visible blood layering in anterior chamber on examination 5
• Can cause blurred vision and requires ophthalmology evaluation for risk of rebleeding and elevated intraocular pressure 5, 6

Traumatic Iritis/Uveitis

• Presents with photophobia, pain, and blurred vision 7
• May have cells and flare in anterior chamber without frank blood 7

Vitreous Hemorrhage or Retinal Pathology

• New onset flashes or floaters carry a 2% risk of developing retinal breaks in weeks following trauma 4
• Can cause significant vision loss 4

Essential Initial Assessment Components

History Elements

• Document exact mechanism (high-velocity projectile vs. blunt impact) 4, 8
• High-velocity mechanism by itself, even with normal visual acuity, should prompt urgent ophthalmologist consultation 8
• Timing of injury and progression of symptoms 4
• Visual symptoms: vision loss, flashes, floaters, peripheral visual field loss, diplopia 4

Physical Examination Priorities

• Measure visual acuity first—this is the most important prognostic indicator 4
• Pupillary examination for afferent pupillary defect (indicates optic nerve or severe retinal injury) 4
• Test extraocular movements in all directions to identify restriction or entrapment 4
• Measure intraocular pressure 4
• Examine for hyphema, irregular pupil, or visible globe injury 4, 5
• Perform forced duction test only if open globe is definitively excluded (distinguishes restriction from paresis) 2, 4

Imaging Recommendation

CT orbit without contrast with thin-section cuts and multiplanar reconstructions is the imaging study of choice 1, 3, 4

• Sensitivity of 94.9% for detecting fractures, soft tissue injuries, hemorrhage, and intraorbital foreign bodies 3, 4
• Superior for identifying integrity of osseous orbit and detecting muscle entrapment 1, 2
• MRI is contraindicated if metallic foreign body is suspected 1, 4
• Contrast is typically not needed in trauma setting 1

Urgent Ophthalmology Referral Indications

Same-day ophthalmology consultation is required for: 4

• Restricted eye movements or diplopia
• Suspected orbital fracture
• Signs of retinal pathology (vitreous hemorrhage, pigment)
• Hyphema
• Any concern for open globe
• High-velocity mechanism of injury (even with normal visual acuity) 8

Critical Pitfall to Avoid

Normal visual acuity on presentation is not reassuring in high-velocity sports injuries 8. Only 1.2% of pediatric eye trauma patients had decreased visual acuity on final follow-up, but high-velocity mechanism was the strongest predictor of final impaired vision 8. Sport injuries and anterior chamber involvement were significantly more common in the high-risk group requiring ophthalmological care 8.