Acute Glaucoma after Dilated Eye Exam in a Patient With Hyphema, Retinal Detachment, and Vitreous Hemorrhage

A 55-year-old man presented to the emergency department (ED) with complaints of decreased visual acuity and right eye pain after his airbag deployed during a motor vehicle collision. Examination revealed normal vital signs, right eye redness with tearing, a circumferential hyphema of the right eye not involving the pupil, and abrasions over the right eyebrow. The upper and lower lids were both swollen, but could be retracted for an exam. Visual acuity was 20/20 in the left eye, and 20/200 in the right eye. Slit-lamp exam additionally revealed multiple small corneal abrasions. The retina could not be visualized by funduscopic exam. ED bedside ultrasound with a high-frequency linear probe was used to visualize the globe. This examination demonstrated a large retinal detachment with accompanying vitreous hemorrhage (Figures 1 and 2 and Video Clip S1, available as supporting information in the online version of this paper). The patient was thus diagnosed with hyphema, retinal detachment, vitreous hemorrhage, and corneal abrasions, and ophthalmology was consulted based on these findings. After interviewing the patient, atropine was instilled into the eyes for a dilated exam. This allowed direct visualization of both the retinal detachment and the vitreous hemorrhage. The patient was ultimately admitted to trauma services for several other injuries. During the next day, he developed an acute glaucoma due to the hyphema and possibly related to the atropine drops used for dilatation. This condition was recalcitrant to Diamox and eventually required paracentesis of the anterior chamber. The patient was ultimately discharged after being treated for his injuries and his vision returned to normal. Although acute glaucoma may be a known complication of hyphema alone, such a condition may be incited or exacerbated by pupillary dilatation. This case certainly illustrates the advantage of high-frequency ultrasound examination of the eye over a dilated eye exam, especially in cases of an existing hyphema.

Figure 1.  Ultrasound image showing retinal detachment.

Figure 2.  Ultrasound image showing vitreous hemorrhage.