Conditions · Ophthalmology and ENT
Ocular trauma: hyphema and open globe injury !
Eye injuries range from blood in the front of the eye (hyphema) to a full-thickness wound of the eyeball (open globe), an emergency that can cost the eye.
Updated 2026-11-01
Structures involved
Tap one to see what it is and open it in 3D.
Why it happens
- Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does
- Aqueous humor and intraocular pressure
What it is
Hyphema is bleeding into the anterior chamber, usually after blunt trauma tears vessels of the iris or ciliary body. An open globe injury is a full-thickness wound of the cornea or sclera, by rupture from blunt force or laceration from a sharp object or projectile.
Who gets it
Eye trauma is a leading cause of one-eye blindness, mostly in young men. Typical settings are assaults, road traffic, work with hammers and metal, sport, fireworks and, in conflict areas, blast injuries.
Causes
- Blunt trauma (fist, ball, elastic cord, fall): hyphema and globe rupture
- Sharp objects and high-speed projectiles (metal chips from hammering or grinding, glass): lacerations and intraocular foreign bodies
- Spontaneous hyphema with clotting disorders, anticoagulants, iris new vessels or tumours
Risk factors
- Young male sex
- Work or hobbies without eye protection (hammering metal, grinding, construction)
- Violence, alcohol and road traffic crashes
- Fireworks
- Sickle cell disease or trait and anticoagulant use (worse course of hyphema)
Pathophysiology
Blunt force compresses the eye front to back and stretches it sideways, tearing iris root and ciliary body vessels so blood fills the anterior chamber; red cells and clot can block the trabecular meshwork and raise eye pressure. Stronger force bursts the globe where the wall is thinnest, at the limbus or behind the rectus muscle insertions. A penetrating wound opens the eye to infection and lets intraocular contents prolapse; rarely, exposed uveal antigens trigger inflammation in the other eye (sympathetic ophthalmia).
Classification
- Closed globe: contusion (including hyphema) or partial-thickness laceration
- Open globe: rupture (blunt) or laceration (penetrating, perforating, or with an intraocular foreign body)
- Hyphema graded by the height of the blood level, from microhyphema to total (eight-ball) hyphema
Symptoms and signs
- Blurred or reduced vision
- Eye pain and sensitivity to light
- Visible layer of blood in the lower anterior chamber (hyphema)
- Irregular or teardrop-shaped pupil, a shallow anterior chamber or prolapsed dark uveal tissue (open globe)
- Extensive subconjunctival haemorrhage after a blow
Diagnosis
- Clinical
- Mechanism of injury, visual acuity and inspection without pressing on the eye. If an open globe is suspected, examination stops: no pressure measurement and no eyelid forcing. In hyphema, slit-lamp grading and intraocular pressure once an open globe is ruled out.
- Tests
- Seidel test with fluorescein for aqueous leak. Sickle cell screening in Black and Afro-descendant patients with hyphema; clotting tests when bleeding is spontaneous or recurs.
- Imaging
- Orbital CT to look for an intraocular foreign body, a ruptured globe and fractures. MRI is avoided when a metal foreign body is possible. Gentle ultrasound only when an open globe has been excluded or by a specialist.
Differential diagnosis
- Corneal abrasion or foreign body
- Traumatic iritis
- Subconjunctival haemorrhage alone
- Chemical eye injury
- Orbital blowout fracture or retrobulbar haemorrhage
Goal of treatment
In open globe, prevent further loss of eye contents and infection until urgent surgical repair. In hyphema, prevent rebleeding, control eye pressure and protect the cornea and optic nerve.
Treatment
- Acute
- Suspected open globe: rigid shield without pressure (no patch), leave any protruding object in place, nothing by mouth, antiemetics and pain control to avoid straining, systemic antibiotics, tetanus prophylaxis and urgent ophthalmology referral; no topical drops.
- Surgical
- Open globe: exploration and layered closure of the cornea and sclera, removal of foreign bodies and intravitreal antibiotics as needed; enucleation only for a non-salvageable eye.
- Conservative
- Hyphema: rest with the head raised, a protective shield, and avoiding antiplatelet drugs and anti-inflammatory painkillers.
- Medical
- Hyphema: topical steroids and cycloplegics, and pressure-lowering drops when the pressure is high (some classes are avoided in sickle cell disease).
- Follow-up
- Daily checks of vision, eye pressure and blood level in the first days; nursing care keeps the head raised, the shield on and watches for pain, vomiting and new bleeding.
Complications
- Rebleeding and secondary glaucoma
- Corneal blood staining
- Post-traumatic endophthalmitis
- Traumatic cataract, retinal detachment and angle-recession glaucoma years later
- Sympathetic ophthalmia in the uninjured eye
- Permanent vision loss or loss of the eye
Prognosis
Small hyphemas usually clear in about a week with good vision. Open globe injuries have a guarded outlook that depends mostly on the initial visual acuity, wound size and location (worse behind the rectus insertions), retinal involvement and infection.
Prevention
- Protective eyewear for work with hammers, grinders or chemicals and in risky sports
- Safe handling of fireworks
- Seat belts and road safety
Test yourself
Think of the answer, then tap the question to see it.
What is the most important first-aid measure for a suspected open globe injury?
A rigid protective shield without pressure on the eye, leaving any embedded object in place, then urgent ophthalmology referral.
Which imaging test is used to look for an intraocular foreign body, and which is avoided?
Orbital CT is used; MRI is avoided because a metal foreign body may move.
What does a positive Seidel test indicate?
Aqueous humour leaking through a full-thickness corneal wound, seen as dilution of fluorescein dye.
Why is sickle cell status important in a patient with traumatic hyphema?
Sickled cells block the trabecular meshwork and raise eye pressure, and the optic nerve tolerates high pressure poorly in sickle disease.
When is rebleeding most likely after a traumatic hyphema?
In the first few days after injury, usually within the first week.
Related conditions
- Orbital floor (blowout) fracture
- Corneal abrasion and ocular foreign body
- Chemical eye injury
- Retinal detachment
- Cataract
- Endophthalmitis
- Open-angle glaucoma
- Sickle cell disease
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Globe Injury (Merck Manual Professional Edition, 2024); Hyphema (StatPearls (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.
