• Trauma is the most common cause, often resulting from a direct blow from a projectile object such as a ball, air pellet or BB, rock, or fist.





  • A hyphema is a collection of blood, mostly erythrocytes, that layer within the anterior chamber.
  • Direct force to the eye (blunt trauma) forces the globe inward, distorting the normal architecture.
  • Intraocular pressure rises instantaneously causing the lens/iris/ciliary body to move posteriorly, thus disrupting the vascularization with resultant bleeding.
  • Intraocular pressure continues to rise and bleeding stops when this pressure is high enough to compress the bleeding vessels.
  • A fibrin-platelet clot forms and stabilizes in 4 to 7 days; this is eventually broken down by the fibrinolytic system and cleared through the trabecular meshwork.











  • Complications include rebleeding, decreased visual acuity, posterior or peripheral anterior synechiae, corneal bloodstaining, glaucoma, and optic atrophy. Patients may need surgical or medical management for glaucoma.
  • Patients who are more likely to rebleed include black patients (irrespective of sickle cell/trait status),7,8 patients with a grade 3 or 4 hyphema, and patients with high initial intraocular pressure.
  • Warn patients that they may have angle recession from traumatic causes of the hyphema. This will predispose the patient to a lifetime risk of traumatic glaucoma, which can cause blindness without any symptoms. These patients need to be monitored regularly by an ophthalmologist for increased pressure and glaucomatous nerve changes.



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A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

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Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.


Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?

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The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.



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