David Bowie eyes..

As we mourn the passing of the Space oddity, here's an eye one for all you ED heroes. It’s a Sunday afternoon in minors and the triage nurse comes to tell you she’s just triaged a young man with ‘different colour eyes.’  He was playing Futsal (a kind of football in fashion at the moment) with all the young dudes when the ball ricocheted off an opponent’s knee and hit him in the face.  Its a bit sore and he’s really worried as he ‘can’t see anything,’ out of his left eye.  He doesn’t wear glasses or contact lenses and his formal visual acuity is recorded at right eye 6/5 and left eye light/dark but no detail. You take a closer look with a pen torch and discover the apparently brown left eye is actually red.  What is the diagnosis? And how many Bowie songs are listed in this post?

This is the early presentation of a traumatic hyphema (a collection of blood or clot in the anterior chamber, which if large enough is usually visible to the naked eye). The complete guide to Hyphemas for absolute beginners is here.  If the whole chamber is full this is known as an ‘8-ball hyphema’ and is important as it may precipitate secondary angle closure.  However, in this case the blood may well still be settling out to give a more defined fluid level - the as yet unpublished "Horne sign" (my ongoing search for Fame) is when the patient describes vision that is normal at rest but goes blurry on standing/moving, and then gradually settles again, and is sometimes described by patients with smaller hyphemas. Hyphema is no more common in young americans than anyone else.

What are you going to do about it?
This patient needs an emergent ophthalmology opinion, this cannot wait until the next day, thus a phone call to the on-call eye registrar is needed.  In the meantime this patient should be managed with pharmacological control of pain (there is a debate about re-bleeding with NSAIDs) and if on a bed, the head needs to be elevated - letting the blood settle and reducing the incidence of chronic changes (even up to five years) from trabeculae getting clogged.
Typically these cases are followed up the following day at the REI after initial medical management.  There is a re-bleeding risk within the first five days but typically only 5% of patients will require surgery.   Glaucoma is the feared late complication.  Prognosis is directly related to the degree of anterior chamber filling with blood and other associated injuries.

And for those of you who wonder about Bowie's famous heterochromia, it wasn't; he had a permanently dilated pupil after an injury as a child. And the number of Bowie songs included in this text? Post the answer as a comment if you dare...

​Thanks Aaron.