Injured During a Basketball Game, a Boy's Vision Goes Dark

Jessica Lee, MD; Ronald C. Gentile, MD


April 13, 2017

Clinical Presentation

A 15-year-old boy was evaluated for loss of vision in his left eye, which was accidentally poked 2 days earlier while playing basketball. The patient reported that an opposing player inadvertently poked him with his finger in the eye along the inferior and medial portion of the left lower lid.

The patient recalled severe pain after the injury, with foreign body sensation that felt better with his eye closed. The pain subsided shortly after the incident, without medications. The patient realized his vision was completely dark in his left eye 2 days later and reported it to his mother, who brought him immediately to medical care. The patient had no significant medical or surgical history.

Visual acuity was 20/20 in the right eye and no light perception in the left eye. Confrontational visual fields were full in all four quadrants in the right eye; no responses were elicited in the left eye. Color vision using Ishihara plates was similar with 6/6 correct in the right eye, and no control plates could be seen in the left eye. External examination revealed mild erythema and ecchymosis along the medial aspect of his left lower lid. Ocular motility was normal in both eyes, without any deviation noted. Examination of the pupils revealed normal-sized pupils with no reaction to light in the left eye and a complete left afferent pupillary defect.

Anterior segment examination of the left eye revealed a small subconjunctival hemorrhage involving the inferior nasal conjunctiva, with a small area of superficial conjunctival abrasion that stained with fluorescein. The cornea had minimal stromal edema, and the anterior chamber was normal depth with 2+ pigmented cells. Intraocular pressures were 16 mm Hg in the right eye and 12 mm Hg in the left eye.

Posterior segment examination of the right eye was normal but in the left eye revealed pre- and peripapillary hemorrhage, obscuring some of the details of the optic nerve head margins. The optic disc cup was deep, with an absence of the normal centrally exiting retinal blood vessels. There was both superficial and deep retinal whitening extending horizontally from the optic nerve with extension into the macula, only sparing a portion of the inferior macula (Figure 1).

Figure 1. Fundus photo of the left eye, revealing pre- and peripapillary hemorrhage.

Peripheral retinal examination revealed no retinal tears, holes, or detachment in the left eye.

Fluorescein angiography revealed hypofluorescence with blockage from the hemorrhage and nonperfusion of the retinal vessels superiorly and nasally (Figure 2).

Figure 2. Fluorescein angiography of the left eye at 29 seconds.

B-scan ultrasound of the left eye revealed an enlarged area of hypolucency behind the optic nerve head with vitreous echoes exiting it (Figure 3). CT of the orbits was performed and revealed no orbital or optic nerve canal fractures.

Figure 3. B-scan ultrasound of the left eye.


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