To see views enlarged, click on the individual pictures...

A 19-year-old, African-American male reports to the emergency room at midnight. He states that 3 days prior to presentation he was punched in the eye and has had decreased vision in the eye and pain ever since.  He has no prior eye diseases or trauma. On examination, he now has hand motion (HM) vision in the affected eye and an IOP of 70 mmHg (the IOP in the other eye is 14mmHg).  It is now 3 AM and you are about to give the patient IV Diamox to lower the IOP. You remember that you should check a “blood test” before giving Diamox in such patients.

1.	The correct lab test to order in this patient is:
	c -- sickle cell prep and hemoglobin electrophoresis All patients of African or Mediterranean descent should be screened for sickle cell anemia as such patients are at increased for complications from a hyphema and should be managed/monitored very conservatively.
2.	All of the following are associated with a higher risk of a poor clinical outcome EXCEPT:
	b -- absence of corneal staining The following are associated with a higher risk of a poor clinical outcome in patients with a hyphema: (1) Poor VA at presentation (20/200 or worse), (2) Positive Sickle cell disease/trait, (3) Large initial hyphema size, greater than ½ the anterior chamber, (4) medically uncontrolled IOP, and (5) delayed presentation to the ophthalmologist.  This presented case has many of these risk factors already and if the patient has sickle cell disease, then this will also affect treatment strategies.
3.	All of the following are indications for surgical evacuation of a hyphema EXCEPT:
	c -- a visual acuity of 20/200 or better Topical Beta-blockers are safe to use in such patients, but other medicines are associated with the following risks: Topical prostaglandins - may promote inflammation Systemic diuretics (Diamox or Mannitol) - may promote sickling because of an induced systemic acidosis and/or volume contraction. Miotics - are vaso-active and may promote inflammation If the patient’s IOP and hyphema can not be controlled or treated medically, a surgical evacuation of the hyphema may be indicated in the following situations: Corneal stromal blood staining Significant visual deterioration Total AC filling with blood Persistent clot in the angle for 7 days An IOP >50 for 5 days or >35 for 7 days (however, in patients with sickle cell disease the treating ophthalmologist should have a much lower threshold for considering a surgical evacuation)