Definition: bleeding in the anterior chamber of the eye.
Presentation: The mechanism of injury in an athlete is frequently blunt trauma to the eye damaging the microvasculature of the iris. Bleeding can occur spontaneously, usually in association with sickle cell disease.
Evaluation: A blood level will be noted in the anterior chamber of the eye.
Management: Initial management includes eye shielding, maintaining the head in a relatively upright position, discontinuation of nonsteroidal anti-inflammatory drugs and anticoagulants, and bedrest for 4 d. Consider hospitalization if intraocular pressure is increased, blood fills greater than one third of the chamber, or in athletes with a coagulopathy. Urgent ophthalmology referral is warranted as uncontrolled bleeding can lead to glaucoma and blood staining of the cornea. Monitor for re-bleed which can occur after 3 to 5 d. Timing of return to play is determined in consultation with ophthalmology.
Vitreous Hemorrhage (2)
Definition: bleeding in the posterior chamber/vitreous humor of the eye.
Presentation: acute reduction of vision which can be due to trauma. Chronic diseases which cause retinopathy, such as diabetes or sickle cell, can predispose an athlete to this condition.
Evaluation: On fundoscopic examination, the lens may be clear but the fundus is difficult to visualize (i.e., obscured by bleeding). Red reflex can be lost as well.
Management: Refer urgently to ophthalmology and discontinue any anticoagulants or nonsteroidal anti-inflammatory drugs.
Retinal Detachment (1,2)
Definition: detachment of the neurosensory layer of the retina from the underlying choroid and epithelium.
Presentation: Flashes, floaters, and painless vision loss. Trauma can be the mechanism of injury, however, it can be atraumatic, especially in endurance athletes. Myopia is a significant risk factor.
Examination: On fundoscopic examination, elevation, and folding of the peripheral retina may be seen.
Treatment: Referral to ophthalmology for laser or surgical correction should be immediate as permanent vision loss can occur.
Corneal Abrasion (1–3)
Definition: Defect in the corneal epithelial surface.
Presentation: Eye pain, photophobia, foreign body sensation, and tearing.
Evaluation: Topical anesthetic may be used to help improve tolerance of the eye examination (see caution below). Examine with fluorescein and cobalt blue light to locate the lesion. Check for a hidden foreign body by everting the eye lids. Test visual acuity.
Treatment: Topical anesthetic should not be prescribed (delays healing, toxic to epithelium, and masks worsening symptoms). An eye patch is not recommended. Topical antibiotics can be prescribed, however there is a lack of evidence for this. Refer for the following: visual acuity worse than 20/40, ulceration/erosion develops, or abrasion does not heal within 4 d. In those wearing contact lenses, special precautions should be taken including pseudomonal coverage, daily re-evaluation for complications, and no contact lens use until healed. Return to play need not be delayed if visual acuity is normal. If a foreign body is present, removal can be attempted with a saline moistened cotton tip applicator and irrigation. If the object was metallic and a rust ring is noted, the athlete should be referred for further care.
Orbital Blowout Fracture (1,2)
Definition: Fracture of the osseous walls of the orbit.
Presentation: Direct trauma resulting in periorbital edema, ecchymosis, painful extra ocular movements, proptosis, enophthalmos, or ipsilateral nose bleed.
Evaluation: Observe for restricted gaze, especially upward (caused by entrapment of the inferior rectus) and resultant diplopia. Check for numbness of the cheek/mouth/nose (injury to V2 can occur).
Treatment: Send for emergent CT to assess extent of injury.
Globe Rupture (1,2)
Definition: complete breach of the cornea or sclera.
Presentation: severe pain, decreased vision, hyphema, 360 degree subconjunctival hemorrhage, frank tissue prolapse.
Evaluation: Positive Seidel test — fluorescein turns green under blue light due to aqueous humor dilution.
Treatment: Place an eye shield and refer to ophthalmology emergently. Lack of recognition can lead to infection and blindness. Schedule an analgesic and antiemetic to avoid valsalva which can cause further damage.