Blunt Trauma-Induced Hyphema and Organised Blood Clot Presenting as Acute Angle-Closure Glaucoma

We report a rare instance of blunt trauma-induced traumatic hyphema with organised blood clot, manifesting as acute-onset pupillary block glaucoma with very high intraocular pressure, which necessitated immediate surgical removal of the blood clot. CASE REPORT A 65-year-old female patient presented with a history of trauma to the right eye (RE) with a 10-year-old child's foot, following which she had decreased vision associated with pain, headache and vomiting for 3 days. She gave history of undergoing cataract surgery in RE 2 years ago. Her best corrected visual acuity (BCVA) in RE was perception of light (PL+) and in left eye (LE) was 6/6. Ocular examination of RE revealed lid oedema and ecchymosis in the periorbital region. A diffuse conjunctival congestion was noted with diffuse corneal epithelial oedema and pigments on the endothelium. Her anterior chamber (AC) appeared shallow with iridocorneal contact temporally and superiorly, with a 3-mm hyphema and a large blood clot at the pupil plane [Figure 1a]. The pupillary reaction, lens status and the posterior segment status could not be assessed. The intraocular pressure (IOP) was 56 and 12 mmHg in RE and LE, respectively. Her B-scan did not reveal any significant abnormality [Figure 1b]. Ultrasound biomicroscopy (UBM) of RE revealed a shallow AC with a hyperreflective echo behind the cornea. The iris appeared to be pushed forwards all around with 360° iris bombe and a hyperreflective echo between the iris and intraocular lens, suggestive of organised blood clot causing pupillary block glaucoma [Figure 1c and d].Figure 1: (a) Slit-lamp photograph of RE showing corneal oedema and shallow anterior chamber with a 3-mm hyphema and a large blood clot in the pupillary area. (b) USG B-scan RE image showing no evidence of vitreous haemorrhage or choroidal detachment. (c and d) Ultrasound biomicroscopy RE image showing shallow AC with a hyperreflective echo behind the cornea and 360° iris bombe (white asterisk) with a hyperreflective echo between the iris and IOL, suggestive of organised blood clot causing pupillary block glaucoma. AC = anterior chamber, IOL = intraocular lens, RE = right eye, USG = ultrasonographyThe patient was started on steroid eye drops (prednisolone acetate 1% e/d four times a day) along with strong cycloplegic (atropine sulphate 1% e/d three times a day [TID]), oral (T. acetazolamide 250 mg TID) and topical antiglaucoma medications (dorzolamide hydrochloride 2% e/d twice daily [BD], timolol maleate 0.5% e/d BD, brimonidine tartrate 0.2% e/d BD), and an oral analgesic, anti-inflammatory medication. Her anterior segment examination showed no changes when she was reviewed after 3 days. However, her IOP had dropped to 30 mmHg. Subsequently, she underwent AC wash with removal of the organised blood clot and release of posterior synechiae on the next day [Figure 2a-c]. At 2 weeks postoperative visit, her BCVA improved to 6/12 in RE and IOP dropped to 10 mmHg with a clear cornea and a well-formed AC [Figure 2d].Figure 2: (a-c) Intraoperative images showing surgical removal of blood clot over the pupillary area along with posterior synechiolysis and anterior chamber wash. (d) Postoperative image showing a clear cornea, well-formed AC and PCIOL. AC = anterior chamber, PCIOL = Posterior chamber intraocular lensDISCUSSION Blunt and penetrating trauma to the eye can result in traumatic angle-closure glaucoma.[1-3] In patients with suspected pupillary block glaucoma, gonioscopy is imperative to confirm the diagnosis. However, it may be hampered due to associated corneal oedema, inflammation or hyphema. UBM plays a crucial role in such rare instances to diagnose the associated zonular laxity and lens subluxation to decide the appropriate treatment protocol. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and that due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.