Question

3. Case Study: Hyphema

Johnny is a 10-year-old boy who seeks care after being hit in the right eye with a stuffed snake by his brother 15 minutes before arrival.

Subjective Data: Johnny complains of light sensitivity. Vision in the right eye is blurred.

Objective Data

Vital signs: temp, 36.8º C; pulse, 90 bpm; resp, 18 breaths/min; blood pressure, 110/60 mm Hg

Pupils: Left, 3 mm briskly reactive to light. Right, 3 mm and sluggishly reactive to light

Visual acuity: Right eye unable to see chart; left eye 20/15

Approximately a 30% hemorrhage is noted to the anterior chamber of the right eye with an intact globe.

Questions:

1. Johnny is at risk for what complications?
2. What measures may help prevent these complications?
3. What should the nurse do in this situation? Prioritize these actions.

Answer 1

Hyphema is referred to as the accumulation of red blood cells in the anterior chamber of the eye.Here in this case,the cause is blunt trauma and there is no evidence of an open globe injury.There is a 30% hemorrhage in the AC which can resolve by itself under medical management as the eye absorbs the blood in few weeks.A surgical intervention(hyphema drainage) can be done if the bleeding continues or the intra ocular pressure continues to rise.

Complications of hyphema.

1.Obstruction of trabecular meshwork with associated intraocular pressure elevation,which may lead to glaucoma if unresolved.

2.Peripheral anterior synechiae,characterised by the adhesion of peripheral iris to the angle.

3.Posterior synechiae where iris adheres to the lens and blocks the movement of aqueous fro posterior cyber to anterior chamber.both types of ayacha can lead to glaucoma.

4.Corneal bloodstaining.

5.Rebleeding.

6.Ambylopia.(lazy eye)

7.Optic nerve damage.

8.Permenant vision loss.

Early management prevents complications.

As per the details provided,this case can be managed conservatively, with an eye shield, limited activity, and head elevation.Child should be monitored closely during the first few days after injury as this is the highest risk time frame for rebleeding. Maintaining head elevation of at least 45 degrees will allow the hyphema to settle inferiorly within the anterior chamber. This avoids central visual obstruction, as well as limits both corneal endothelial and trabecular meshwork exposure to red blood cells.Limited activity and proper bedrest should be ensured.Medical management includes topical corticosteroids,topical cycloplegic agents and oral betablockers,alpha agonists and hyperosmotic agents to reduce iop.Surgical management includes drainage of hyphema by an anterior approach followed by an anterior chamber wash.This will only be done if the condition is not resolved making the child at risk for complications.

Nursing responsibilities.

The child will be having pain in the affected eye,managing which should be the first priority.

1.Assess the type, intensity and location of pain.

2.Use pain scale levels to determine the dose of analgesics.

3.Maintain bed rest in an upright position or the position of head of 60º.

4.Perform eye bandage and apply eye shield on the affected part.

5.Give a cold compress to reduce pain and swelling.

6.Give sedation to minimize activity.

7.Give proper health education to parents about the condition and management and help them determine whether they want the child to be hospitalized for observation or they want to go home and come for regular follow ups.

8.Instruct the parents about topical applications and importance of adherence to the treatment and follow ups.The signs and symptoms of elevated iop must be properly understood by the parents.