Corneal blood staining in a blind eye: A management and rehabilitation dilemma

A 17-year-old boy presented with yellowish discoloration in his left eye for 4 months. He had sustained blunt trauma to the same eye at 9 years old, resulting in a traumatic rhegmatogenous retinal detachment (RD). He subsequently underwent multiple vitreoretinal surgeries over time, with no meaningful visual recovery. At 16 years old, he was slapped, resulting in hyphema in the same eye. B-scan revealed a total RD. An anterior chamber washout was performed, along with pars plana vitrectomy, silicone oil endotamponade, and intravitreal antivascular endothelial growth factor injection. Extensive macular scarring was observed, with a best-corrected visual acuity of hand motion close to face. Persistent hyphema was noted during the postoperative period, likely due to underlying neovascularization. The intraocular pressure (IOP) remained in the midteens the whole time. Now, on examination, he had a plain 6/6 acuity in his unaffected right eye. The consensual light reflex was poor in the right eye. The affected left eye had perception of light, with an inaccurate projection of rays. Slit-lamp examination revealed a honey-colored discoid opacity in the corneal stroma, darker at the center, with a clear distinction from the lighter periphery [Figure 1a]. The anterior segment had normal peripheral depth; however, 1 mm of dark red hyphema was present inferiorly, indicating a continuous bleed. The peripheral iris ring was faintly visible. The eye had gone into sensory exotropia [Figure 2a].Figure 1: (a) Corneal blood staining, with fresh bleed inferiorly; (b) 7 months later, there was some degree of spontaneous resolution, with corneal neovascularizationFigure 2: (a) Sensory exotropia of the left eye due to poor vision for the last eight years; (b) Inflamed red eye, with a prosthetic contact lens when presented after seven monthsGiven the poor visual prognosis, keratoplasty was deferred. The patient was fitted with a prosthetic contact lens for cosmetic rehabilitation, but reported persistent discomfort and discontinued use. The patient was lost to follow-up and presented at 7 months with redness [Figure 2b]. The central opacity had reduced, with a lighter yellow peripheral ring and surrounding corneal vascularization. There was no hyphema [Figure 1b]. He was prescribed topical lubricants and low-dose loteprednol. On a recent teleconsultation, he denied the perception of light, but a quiet eye. Discussion Corneal blood staining (CBS) is a rare and serious complication, usually following an ocular trauma. There is corneal endothelial damage with loosening of tight junctions.[1] Due to long-standing hyphema, persistent overload with hemoglobin leads to keratocyte necrosis. Hemosiderin deposits in the corneal stroma,[2] resulting in opacity and a severe visual handicap. It is often associated with raised IOP, i.e., 25 mmHg or more for more than 5 days.[1] The opacity can take up to 3 years or more to clear by phagocytosis, starting peripherally.[3] Our patient’s eye was visually non-functional for 7 years. The second trauma caused hyphema, followed by CBS despite a timely surgical intervention. While elevated IOP is classically implicated, our case reinforces that endothelial compromise and recurrent hemorrhage alone may be sufficient. Our management focused on cosmetic rehabilitation, with a cosmetic contact lens. However, intolerance limited its use. This case illustrates the practical challenges of managing anterior segment complications in a blind eye. It also underscores the importance of preventive education for monocular patients. Management must be individualized. Patient-centered counseling and long-term follow-up are essential in such complex cases. Data availability statement Data will be made available on reasonable request to the corresponding authors. 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.