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 Table of Contents  
CASE REPORT
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 69-70

A rare presentation of corneal blood staining: Does Intraocular pressure matter?


Department of Ophthalmology, Arunodaya Deseret Eye Hospital, Gurugram, Haryana, India

Date of Submission09-May-2022
Date of Acceptance16-Aug-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Sahebaan Sethi
House No. 2, 3rd Floor, Sector 55, Gurugram - 122 011, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1131_22

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  Abstract 


We report an easily missed diagnosis of the blood-stained cornea that can simulate crystalline lens in the anterior chamber (AC), especially when associated with low intraocular pressure (IOP), a rare occurrence. A 10-year-old boy presented with loss of vision in the left eye since 15 days following a cricket ball injury. Ocular examination revealed an amber-colored disciform appearance in the cornea and visual acuity of light perception. The eye was hypotonus. The patient underwent an ultrasound B-scan, which demonstrated an infero-posterior displacement of the lens. The empirical diagnosis of crystalline lens in AC was then revised and a rare association with low IOP was picked up.

Keywords: Blood staining of the cornea, blunt trauma, corneal blood staining, low intraocular pressure, ultrasound B-scan


How to cite this article:
Sethi S, Sethi A. A rare presentation of corneal blood staining: Does Intraocular pressure matter?. Indian J Ophthalmol Case Rep 2023;3:69-70

How to cite this URL:
Sethi S, Sethi A. A rare presentation of corneal blood staining: Does Intraocular pressure matter?. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:69-70. Available from: https://www.ijoreports.in/text.asp?2023/3/1/69/368127



Corneal blood staining (CBS) is defined as the deposition of hemoglobin and its breakdown products into the cornea. It usually occurs following total hyphema, aka 8-ball hyphema of prolonged duration, associated with high intraocular pressure (IOP).[1] An IOP of more than 25 mmHg, for more than 5 days can result in CBS. Apart from trauma, other causes include intraocular surgery or bleeding in the anterior chamber (AC) by other causes. Total CBS precludes visualization of intraocular structures, making it difficult to identify damage to other structures in a setting of trauma. Ocular imaging, e.g., ultrasound B-scan, anterior segment optical coherence tomography (AS-OCT), and ultrasound biomicroscopy thus play a vital role in determining the visual prognosis and management plan in these cases.

In cases of total hyphema, the management should aim at preventing CBS, as it can cause loss of vision due to corneal opacity, and need corneal transplantation.[2] We report a case to appreciate an easily missed diagnosis of a blood-stained cornea, as it can simulate a dislocated crystalline lens in the AC especially when not associated with high IOP, a rare occurrence.[3] We also emphasize the importance of an ultrasound B-scan in determining the diagnosis and guiding management.


  Case Report Top


A 10-year-old boy presented with redness in the left eye and loss of vision since 15 days following a blunt injury with a cricket ball [Figure 1]. On examination of the unaffected right eye, the visual acuity was 6/6, N6, IOP-15 mmHg, and ocular examination was unremarkable. In the affected left eye, visual acuity was light perception only. The IOP was unrecordable with Goldmann applanation tonometer (Haag-Streit), and digitally very low. Slit lamp examination showed circumcorneal conjunctival congestion, and a central 7 mm peculiar amber-colored disciform area was seen in the cornea with no focal scarring. The AC had 5 mm hyphema and layered blood clots. There was a total loss of iris tissue. No other details were made out [Figure 2]. Ultrasound B-scan (Accutome) of the left eye revealed a mixed echoic area measuring about 1.5 × 1.3 × 1.4 cm seen in the AC displacing the lens infero-posteriorly [Figure 3].
Figure 1: Left eye injury with a cricket ball (with consent)

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Figure 2: Slit lamp photo exhibiting corneal blood staining

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Figure 3: B-scan of both eyes showing posterior dislocation of the lens in the left eye

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A suspected diagnosis of a crystalline lens in the AC was made. Since the eye was hypotonous, CBS was not our first differential diagnosis. B-scan however suggested displacement of the crystalline lens posteriorly. Following the ultrasound, the diagnosis was reconsidered, and the clinician was pointed toward the blood staining of the cornea. The patient was treated conservatively with topical steroids, cycloplegics, and nonsteroidal anti-inflammatory drugs (NSAIDs) and the poor visual prognosis was explained to the patient.


  Discussion Top


CBS is a complication of hyphema usually associated with increased IOP. The incidence of CBS in traumatic hyphema ranges from 2% to 11%.[4] In the context of blunt trauma, a local concussion can cause corneal endothelial cell rupture and loosening of endothelial tight junctions. The corneal endothelium can also get damaged from direct contact of the corneal endothelium with the iris. With a hyphema present and high IOP, blood can be forced from the AC into the corneal stroma, causing CBS.[1] Clinically, the appearance of CBS includes fine yellow granules in the posterior stroma, followed by red to brown discoloration of the stroma, and then finally ends with green, black, and grey discoloration.[1]

In our case, CBS occurred at low IOP. Clinically, it is important to recognize this entity as it can simulate an anteriorly dislocated lens. CBS occurring in the presence of hypotony is an entity scarcely reported in the literature.[3] This case also highlights the relevance of performing an ultrasound B-scan since another important issue in the management of traumatic hyphema is the identification and treatment of associated ocular injuries, as the presence of hyphema is a hallmark of severe injury. In most patients, the cause of poor vision after resolution of the hyphema is the associated injury and not the hyphema itself. In our case, B-scan helped to differentiate between CBS and the differential diagnosis of the anteriorly displaced crystalline lens.

Another favorable tool can be the AS-OCT scan, as any loss of hyper-reflectivity at the level of Descemet's membrane (DM) can be considered a sign of permanent damage to the DM–endothelial complex, which can cause permanent CBS. This sign is an indication to perform an endothelial transplant to replace the damaged DM. Early presentations where the DM is still visualized on AS-OCT can be managed with AC evacuation. Thus, serial documentation of AS-OCT can also guide the clinician in the management of hyphema.

Our patient was treated conservatively because of a poor visual prognosis most likely due to traumatic optic neuropathy. Steroids, cycloplegics, and NSAIDs were instituted to treat hypotony and prevent rebleeding and pain. Treatment options in cases with favorable visual prognoses include observation. Spontaneous clearing can take up to 3 years, starting at the periphery.[5] Factors that increase the risk of CBS include total hyphema, rebleeding, and endothelial dysfunction.[3] Management options for hyphema with increased IOP include trabeculectomy, AC washout, and pharmacotherapy with topical steroids and cycloplegics.[6] For persistent CBS, penetrating keratoplasty can be considered. Other topical treatment that has been tried with some success is deferiprone, due to its low molecular weight and lipophilic nature.[7]


  Conclusion Top


This case exhibits that CBS can clinically mimic the dislocation of the lens into the AC. It is a diagnosis that needs to be kept in mind and serially monitored to prevent permanent vision loss, even in eyes with low IOP.

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 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.



 
  References Top

1.
McDonnell PJ, Green WR, Stevens RE, Bargeron CB, Riquelme JL. Blood staining of the cornea. Light microscopic and ultrastructural features. Ophthalmology 1985;92:1668-74.  Back to cited text no. 1
    
2.
Walton W, von Hagen S, Grigorian R, Zarbin M. Management of traumatic hyphema. Surv Ophthalmol 2002;47:297-334.  Back to cited text no. 2
    
3.
Beyer TL, Hirst LW. Corneal blood staining at low pressures. Arch Ophthalmol 1985;103:654-5.  Back to cited text no. 3
    
4.
Iftikhar M, Mir T, Seidel N, Rice K, Trang M, Bhowmik R, et al. Epidemiology and outcomes of hyphema: A single tertiary centre experience of 180 cases. Acta Ophthalmol 2021;99:e394-e401.  Back to cited text no. 4
    
5.
Brodrick JD. Corneal blood staining after hyphaema. Br J Ophthalmol 1972;56:58.  Back to cited text no. 5
    
6.
Graul TA, Ruttum MS, Lloyd MA, Radius RL, Hyndiuk RA. Trabeculectomy for traumatic hyphema with increased intraocular pressure. Am J Ophthalmol 1994;117:155-9.  Back to cited text no. 6
    
7.
Chan T, White A, Meades K, Bala C. Novel topical therapy for corneal blood staining. Clin Exp Ophthalmol 2017;45:416-8.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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