Welcome back to Mangled Mondays, where every Monday we talk about another facet of maiming, mangling, mauling, and mistreating your main characters — and all of their friends.
Today we’ll be talking about Hyphemas, a form of bleeding into the eyeball. For the rest of the Mangled Mondays series, [click here].
What Is It?
Sometimes characters get hit in such a way that a blood vessel in the eyeball ruptures, causing blood to pool inside the front of the eye. This is known as a hyphema, and is most visible in the pupil.
A related condition, subconjunctival hemorrhage, is when the character bleeds into the sclera, or white of the eye; it is not covered in this entry.
In a hyphema, a capillary in the eyeball ruptures due to blunt force applied to the eye socket (orbital bones). When this happens, blood is trapped between the iris (colored part of the eye) and the cornea (the surface of the eye).
What results is blood pooling in the bottom of the iris. How much blood there is will depend on the injury.
A typical hyphema…
… heals in less than a week, doesn’t permanently affect vision, and doesn’t require significant management (other than avoiding strenuous activity so the bleeding doesn’t get worse).
However, a hyphema is ultimately a condition of bleeding into an enclosed space. Because of this, severe hyphemas, or hyphemas in characters with hemophilia, sickle cell disease, or who are on anticoagulants like warfarin, can cause significantly elevated pressure in the eye, which can, in turn, cause permanent damage to the eye.
Traumatic hyphema is also often accompanied by a traumatic iritis, which refers to inflammation of the iris. This causes pain, blurred vision, photophobia, and an uneven shape when constricting in response to bright light.
- Blood welling in the iris of the eye.
- Photophobia – pain and sensitivity to light. Contraction of the iris muscles when elevated levels of light hit the eye can cause additional pressure on the hyphema, which is painful.
- Blurred vision when lying down, which progressively gets better as the character sits or stands.
- Headache can be caused by visual disturbances such as hyphema; if this is the case, however, head injury will need to be ruled out by examination and possibly by CT scan.
How Does It Happen?
Hyphemas are exclusively caused by blunt trauma. This can come from a punch, from falling face-first, a skiing accident, a car crash, or any other variation of a blow to the head.
Paintball guns, airsoft guns, etc., are known to cause hyphemas as well, in addition to strikes from bungee cords and other miscellaneous mishaps.
The only care available for a hyphema is an eye patch to protect the eye from light and further injury.
A class of pain medication known as NSAIDs should be avoided, as they increase the risk of bleeding. However, opioid pain medication such as oxycodone (Oxycontin) or hydrocodone (Vicodin) are an option for severe pain.
Surgery / Hospitalization
None unless severe.
Severe hyphemas that endanger the eye overall may require surgery to remove the blood clot from the front chamber of the eye. This is very rare, but it is possible.
In the Austere Environment
The eye will be able to heal on its own, though the character should be restricted from strenuous activities.
The Rocky Road to Recovery
Characters will retain vision in the unaffected eye. In the absence of more serious head injuries, characters will not have any neurocognitive deficits, and motion of all limbs will be retained.
Blurred or total loss of vision on the affected side.
None. The hyphema should heal well on its own. However, blindness to one degree or another is possible if the character is in a high-risk group, as it may cause damage to the retina or optic nerve.
Features of Recovery: Hospital Stay
Characters will be evaluated in the emergency department, and won’t be admitted for a hyphema alone unless it puts significant pressure on the eyeball.
They may be given atropine drops to dilate the eyes for better inspection with an ophthalmoscope and may be seen by ophthalmologists (eye specialists). They may also be given proparacaine or tetracaine, which are anesthetic eye drops; they burn when first applied but feel better a minute or two later. This facilitates examination, but won’t be prescribed to take home.
It’s not unknown for patients to try to steal tetracaine or proparacaine drops to use at home, since these make them feel better in the short term, but they can cause long-term damage to the cornea. They also numb the eye, making it easier to accidental injure by rubbing.
Characters might be given corticosteroid eyedrops, such as 0.1% dexamethasone, to reduce swelling.
Features of Recovery: PT/OT
The New Normal
After the blood drains from the eye, assuming there was no permanent damage, the eye and vision will be back to normal.
Total Recovery Time (Typical)
The characteristic appearance of blood welling in the iris looks as though the eye is going to “drown.”
- Hyphemas are mostly “textural” injuries and are an excuse for your character to wear an eye patch for a week, but they’re not usually disabling over the long term.
- However, if characters are in high-risk groups due to bleeding disorders or medications they take, they can lose their eyesight in the affected eye.
- Hyphemas come from blunt trauma to the head.
- The blood in the eye spreads out when the character lays down, which means they may have no vision in the eye when supine; when standing or sitting, the blood falls to the bottom of the eye due to gravity and vision is at least partially restored.
xoxo, Aunt Scripty
This post is an excerpt from Blood on the Page Volume One: A Writer’s Compendium of Injuries. The book details thirty-one injuries with which to maim, mangle, and maul your characters, as well as nine indispensable articles of Wound Wisdom covering everything from burn stages to suture selection.