Traumatic Mydriasis?

Hello. I have a friend who got hit by a shuttlecock on her right eye. Her doctor told her that the pupil of that eye is enlarged and told her not to tear, as continued tearing may cause blindness. He also told her to be mentally prepared of going blind in the right eye. She also complains of the right eye being uncomfortable in sunlight or glaring light.

I was wondering if this is a case of traumatic mydriasis? And I am also curious about the fact that tearing can cause blindness. Or is it due to increased intraocular pressure or something? Am I missing something here? I am a year 1 medical student in going onto year 2 so I am really interested in this. Thank you very much!

[John C Hagan III, MD, FACS, FAAO]

Hello hattaong. Welcome to the medical profession. You're missing some some important details, OR your friend must have grossly misunderstood what the 'doctor' said or the doctor is practicing outside his/her zone of competency (least likely of the three).  In eye care there are all kinds of "eye doctors". Your friend could be seing a non-physician, non-MD, limited eye care provider (optometrist). She needs to see an Eye MD.

There are no eye conditions that would lead to blindness if the person "tears".  She can go to all the sad movies and read all the books with tragic endings she wishes. (Cry me a river, it won't hurt a thing)

With a direct blow to the eye there are lots of bad things that can happen from rupture of the globe and loss of the eye to no damage at all. Blunt trauma can damage the pupil dilating muscle. It's interesting why this happens. The constrictor muscle is relatively small, shaped like a donut and runs just inside the pupil. Its shape and location makes it more prone to be damaged that the dilator muscle which is shaped like a fan and thinner and larger. So traumatic mydriasis is much more common than traumatic miosis.

Other common problems with moderate trauma to the anterior segment include tramautic iritis (pain, redness, sensitivity to light (photophobia) and some blur.  Also traumatic bleeding into the anterior chamber of the eye (hyphema). This can cause all of the above plus high pressure and may be associated with damage to the posterior segment (retina, vitreous and optic nerve).  During the first 5-6 days after a hyphema there is a chance of a secondary bleed that can be larger and more damaging than the first bleed. For that reason hyphema cases are followed very closely during the first week post injury. Your friend's symptoms suggest traumatic iritis and a need to be on steroid eye drops. After the pain, redness and inflammation has subsided a dilated examination of the posterior segment of the eye with special exam of the peripheral retina (ora serrata visualization). In young people a special type of tear (retinal dialysis) often occurs in major trauma in that area.

If this is going on right now your friend should consider seeing another ophthalmologist. Perhaps you can ask your professors to recommend an ophthalmologist in the community or perhaps she can see someone in your department of ophthalmolgy.

Lastly let me give you some advice that will serve your well. Don't automatically think the worse about "the other doctor".  In a situation like this there often are major problems with communication betwen the first doctor and the patient. Also some patients (probably not your friend) will, for one reason or another, unintentionally and even sometimes intentionally mistate what "the other doctor" said or did. Let me give you an example. I often see patients with posterior vitreous detachments (PVD) I use simple language, I have charts and models to point out the difference between a PVD  and a retinal detachment (RD). I have a well written and concise information sheet to send home with them that outlines the differences between RD and PVD.   In spite of that patients have told their families and personal physicians, "Dr. Hagan said I had a retinal detachment and that I was going blind).   Good luck in your career in medicine. Always give "the other doctor" the benefit of the doubt. Miscommunication is far more common than rank incompetence.

JC Hagan III MD Eye Physician & Surgeon
Editor, Missouri Medicine medical journal

[hattaong]

Thank you very much for your insightful reply. I have asked her again and she revealed the doctor has actually said she is suffering from angle recession and there is some problem with the drainage system of the eye. Am I right to say that this may potentially cause blindness due to the increased intraocular pressure which may injure the optic nerve? In addition, she has admitted that the tearing part was something she picked up on the Internet and not from the doctor's advice. Haha.

I was wondering if her she would be able to regain her full eyesight eventually? As you explained in the previous post, her constrictor muscle is injured, but would it be able to function normally again? About the angle recession, what are the chances of her going blind and how exactly does the doctor rectify the problem? Surgery perhaps?

Just for your information, she has decided to see another opthalmologist.

[John C Hagan III, MD, FACS, FAAO]

Only time will tell if the pupil constrictor recovers full function. A 'recessed angle" does not mean the eye will develop traumatic glaucoma and even if it does it's often decades down the road. Angle recession glaucoma is treatable with drops and/or lasers and surgery is rarely indicated. The likelihood of going blind is very very small if she see's an ophthalmologist yearly and always tells them of the injury and the previous diagnosis of "recessed angle".  

Also it points out the danger of playing racquet sports without eye protection.  WITH CONTACT SPORTS AND RACQUET SPORTS ALWAYS WEAR PROPER ATHLETIC SAFETY GLASSES.

JCH III MD   Ophthalmologist