This patient has a hyphema, which is a collection of blood in the anterior chamber of the eye.  When force is applied to the eye, intraocular pressure increases acutely, causing ruptured blood vessels in the ciliary body and iris.  Hyphemas are most common after blunt ocular trauma (eg, paintball, assault, airbag deployment) but can also occur with penetrating injury.

Typical presentation includes eye pain and blurry vision, with the severity of vision loss correlating with the size of the hyphema.  Anisocoria (unequal pupils) and a sluggish pupillary reflex are common due to torn iris sphincter muscles, and an examination finding of blood between the cornea and lens is diagnostic.

Management of traumatic hyphema involves preventing complications and preserving vision.  An eye shield, bed rest (with head elevation), and glucocorticoid eye drops help prevent rebleeding, which is associated with worse vision outcomes.  In addition, intraocular pressure should be monitored daily because untreated intraocular hypertension can lead to optic nerve injury (ie, glaucoma) and permanent vision loss.

Small hyphemas self-resolve typically within days; however, surgical clot evacuation is required for a large, persistent hyphema or for intraocular hypertension unresponsive to topical and oral therapies.

(Choice A)  Cataract, a painless lens opacity that causes blurry vision, usually develops as a complication of an inflammatory condition (eg, uveitis, scleritis).  Traumatic cataract can occur but most commonly develops after an open globe injury (eg, penetrating trauma), which typically presents with an eccentric or teardrop-shaped pupil, not seen here.

(Choices B and C)  Common risk factors for keratitis, or corneal infection, include prolonged contact lens use and immunosuppression, not blunt trauma or hyphema.  Keratitis, as with other causes of corneal ischemia, can also lead to corneal neovascularization, a condition in which new blood vessels grow into the cornea and cause decreased visual acuity.  Blood in the anterior chamber does not increase this risk.

(Choice E)  Subconjunctival hemorrhage is a painless collection of blood beneath the eye surface that does not affect visual acuity.  The bleeding may be spontaneous or secondary to increased venous pressure (eg, Valsalva maneuver, coughing), but it is not a complication of hyphema.

Educational objective:
A hyphema is a collection of blood in the anterior chamber of the eye that develops following blunt or penetrating ocular trauma.  Management involves preventing complications such as rebleeding and intraocular hypertension, which can result in optic nerve injury and permanent vision loss.