plasminogen to plasmin and therefore delays clot dissolution and theoretically decreases the risk of rebleeding. Studies have shown that topical ACA is as e ective as systemic ACA and avoids the side e ects typically associated with administration such as nausea, vomiting, and hypotension [1]. These agents should be avoided in pregnant patients, patients who have renal or hepatic dysfunction, or those at risk for thromboembolic disease. Intracameral tissue plasminogen activator currently is under investigation and is reserved for large clots of prolonged duration or malignant elevation of intraocular pressure. In addition, elevated intraocular pressure (O 24 mm Hg) can be treated with topical beta-blockers and carbonic anhydrase inhibitors such as acetazolomide. Acetazolomide lowers pH, causing increased sickling, and should be avoided in pediatric patients or those who have sickle cell trait or anemia. Methazolomide is the preferred agent in this situation [21]. Mannitol may be administered for severely elevated intraocular pressure (O 35 mm Hg). Nonsteroidal anti-inflammatory medications and aspirin should be avoided because of the increased risk of rebleeding. Surgery usually is reserved for delayed complications such as corneal staining and persistently elevated intraocular pressures but often is performed early in patients who have sickle cell anemia or trait.

Subconjunctival hemorrhage

Subconjunctival hemorrhage is caused by the rupture of small subconjunctival blood vessels. Although patients may report a prior sneezing or coughing episode or a Valsalva maneuver, some patients may have no recollection of the preceding events. Patients often seek care because of the dramatic appearance. On examination a painless, smooth, bright-red area is noted over the bulbar conjunctiva and is sharply demarcated at the limbus. Visual acuity should be normal. If there is preceding blunt or penetrating trauma, underlying scleral penetration should be considered. Pain on extraocular movements and bloody chemosis also should prompt suspicion for injury to the globe. Subconjunctival hemorrhage should always be distinguished from chemosis: a hemorrhage is flat and smooth, whereas chemosis presents as erythema with edema, and the area is raised. Bilateral or recurrent subconjunctival hemorrhage may require a work-up for bleeding diathesis. Treatment of subconjunctival hemorrhage consists of reassurance and local cold compresses for 24 hours. Subconjunctival hemorrhages heal spontaneously in 2 to 4 weeks.

Injury to the iris and ciliary body

Traumatic iridocyclitis (uveitis)

Blunt injury to the globe may contuse and inflame the iris and ciliary body, resulting in ciliary spasm. Patients may complain of photophobia, blurred vision, and eye pain. Examination reveals conjunctival injection, specifically ciliary flush, cells, and flare in the anterior chamber and a small,