Bilateral Spontaneous Retrobulbar Hemorrhage due to Warfarin Misuse After Sinus Lavage.

While warfarin has historically played an important role in anticoagulation, direct oral anticoagulants have largely supplanted warfarin due to their improved safety profile and reduced need for monitoring. Herein, the authors report the case of a 64-year-old male who developed severe, bilateral retrobulbar hemorrhage following aggressive nasal lavage due to a supratherapeutic international normalized ratio from warfarin misuse. Visual acuity on arrival was hand-motion OD and no-light-perception OS. He underwent bilateral canthotomy with upper and lower lid cantholysis before transfer to a trauma center where his international normalized ratio was greater than 12. Reversal with vitamin K and prothrombin complex concentrate was initiated. Over the course of hospitalization, vision and swelling continued to improve and at 2-month follow-up his visual acuity was 20/20 OD and no-light-perception OS. This case outlines the risk of bleeding associated with warfarin misuse and advocates for the transition of patients to direct oral anticoagulants when possible.

Characteristics of Retrobulbar Hemorrhage Presentation in the Emergency Department.

PURPOSE: To describe demographic and clinical features of emergency department patients presenting with fracture-associated (FA) or fracture-independent retrobulbar hemorrhage (RBH). METHODS: The Nationwide Emergency Department Sample database 2018 and 2019 was used to compare demographic and clinical features of patients with fracture-independent RBH and FA RBH. RESULTS: A total of 444 fracture-independent and 359 FA RBH patients were identified. Demographics such as age distribution, gender, and payer type differed significantly, with young (21-44 years), privately insured males more likely to develop FA RBH and the elderly (65+ years) more likely to develop fracture-independent RBH. Prevalence of hypertension and anticoagulation did not differ, but substance use and ocular-related injuries were more prevalent in the FA RBH. CONCLUSION: Presentations of RBH differ in demographic and clinical features. Further research is needed to explore trends and guide decision-making in the emergency department.

Recurrent Retrobulbar Hemorrhage Associated With CPAP Use After Orbital Fracture Repair.

We present a patient who underwent orbital fracture repair complicated by retrobulbar hemorrhages twice within the first postoperative week. The suspected cause is continuous positive airway pressure (CPAP) use with inappropriate patient-modified settings. The most likely mechanism of action was venous congestion from the extrinsic positive pressure, similar to Valsalva maneuvers increasing orbital vasculature pressure. In our patient, because his orbital blood vessels had recently been cauterized, they were too fragile to handle the engorgement and bled, leading to a retrobulbar hemorrhage. It is possible that at a lower CPAP setting, the vascular congestion would not have been as severe and caused bleeding. We recommend routinely asking patients about CPAP use before orbital surgeries and instructing patients to stop CPAP usage for 1 week after any orbital surgeries if medically cleared.

Spontaneous retrobulbar hemorrhage in the setting of warfarin therapy and latent scurvy diagnosis.

We present a case of spontaneous nontraumatic retrobulbar hemorrhage associated with anti-coagulation therapy and a new diagnosis of scurvy. A 68-year-old male on chronic anti-coagulation therapy presented with a retrobulbar hemorrhage requiring urgent canthotomy and cantholysis. Despite the absence of a supratherapeutic INR and normal clotting factors, the patient continued to have spontaneous hemorrhages within the orbit and elsewhere. Workup revealed a severe vitamin C deficiency consistent with scurvy. Further investigation of dietary history demonstrated an avoidance of all citrus fruit upon starting warfarin due to misunderstanding in medication counseling on avoidance of grapefruit. With repletion of vitamin C and further medication counseling, the patient had no further episodes of spontaneous hemorrhage.

[Retrobulbar Haematoma - a Complication that May Impair Vision]. / Das retrobulbäre Hämatom ­ eine potenziell visusbedrohende Komplikation.

Retrobulbar haematoma (RBH) is a rare complication that may affect vision after a trauma or a surgical procedure. The diagnosis must be made promptly, as only early surgical intervention can adequately prevent irreversible visual impairment. Because of the bony orbital walls, there is hardly any room for the increasing intraorbital volume due to the retrobulbar haemorrhage. This leads to an increase in intraorbital pressure and subsequently to compression of the optic nerve. Symptoms include disorders in ocular motility, ophthalmoplegia, diplopia, conjunctival chemosis, subconjunctival haemorrhage, proptosis, increased intraocular pressure, deterioration in visual acuity, decreased direct pupillary reflex, and a relative afferent pupillary defect. If the cause is traumatic or iatrogenic, prompt lateral canthotomy with cantholysis is the treatment of choice, and successfully lowers pressure in most cases. It can be performed in the emergency room by an ophthalmologist and may even be indicated without previous imaging. As the reconstruction of cantholysis is generally uncomplicated, we recommend performing the procedure when RBH is suspected. If canthotomy with cantholysis does not lead to adequate improvement, surgical orbital decompression must be performed. Supportive treatment should always include systemic steroids.

Spontaneous Orbital Hemorrhage Related to the Extraocular Muscles.

PURPOSE: The authors present the largest series of patients to date of spontaneous hemorrhage in relation to extraocular muscles (EOMs). METHODS: Observational retrospective case series. Institutional review board approval was obtained. RESULTS: Eighteen patients with a mean age of 71 years presented with 20 episodes of spontaneous orbital hemorrhage closely related to an EOM. Most patients woke with unilateral proptosis, pain, and diplopia. Vision was impaired in 25%. Imaging identified a characteristic well-circumscribed hematoma arising within the muscle sheath or intermuscular septum. Three episodes required surgical drainage. All patients had good recovery of vision. DISCUSSION: The authors describe a distinct clinical entity of idiopathic hemorrhages related to EOMs. No patient had an underlying vascular malformation or other lesion. The authors demonstrate that a proportion of these patients have vascular risk factors, namely, hypertension, hyperlipidemia, and antiplatelet use. This study suggests that inferior rectus is the most commonly affected EOM and shows that it is the muscle sheath or intermuscular septum of inferior rectus that is involved, rather than the muscle belly. Most patients can be managed conservatively with good visual outcomes. However, there were 3 exceptional cases that required surgical intervention. CONCLUSIONS: The findings that spontaneous orbital hemorrhages related to EOMs have certain predisposing factors, a characteristic radiological appearance, and a typically benign course will be helpful for clinicians in the management of this condition.

Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians.

INTRODUCTION: Acute retrobulbar haemorrhage (RBH) with orbital compartment syndrome is a sight-threatening ophthalmic emergency requiring treatment with lateral canthotomy and cantholysis (LC/C). However, such cases may present to non-ophthalmic emergency departments (ED) out-of-hours, when specialist intervention is not readily available. We completed a survey of ED physicians to explore experiences of RBH and confidence in undertaking LC/C. METHODS: From February to April 2018, an online survey was sent to ED physicians of all training grades in seven UK locations. The survey comprised a case vignette of a patient presenting with clinical features of RBH with orbital compartment syndrome, with multiple choice questions on the diagnosis, management and onward referral of such cases. Additional questions explored the experience of RBH, LC/C and perspectives on current and future training of ED physicians in this area. RESULTS: 190 ED doctors completed the survey (response rate 70%). While 82.8% correctly diagnosed RBH and 95.7% recognised irreversible visual loss as a consequence of untreated RBH with orbital compartment syndrome, 78.7% indicated that they would initially undertake CT imaging rather than performing LC/C. Only 38.9% had previously encountered a case of RBH and only 37.1% would perform LC/C themselves, with 91.4% indicating that this was due to lack of training. 92.2% felt that more training was required for ED physicians in RBH management and performing LC/C. CONCLUSION: While cases of RBH with orbital compartment syndrome are infrequent, it is important that RBH management with the vital, sight-saving skill of LC/C is added to the United Kingdom Royal College of Emergency Medicine training curriculum. At present, though the majority of ED physicians can identify RBH, the minority are willing or able to undertake LC/C, potentially risking irreversible but avoidable visual loss.

A Case of a Spontaneous Self-resolving Retrobulbar Hemorrhage Following 3,4-Methylenedioxy-methamphetamine Use.

This case report discusses the case of a 23-year-old male patient who experienced retrobulbar pain, diplopia, proptosis, and mild lower eyelid bruising after consuming 3,4-methylenedioxy-methamphetamine. The symptoms settled over 10 days and vision returned to normal without intervention. The authors discuss the differential diagnosis relevant to the presenting complaints and propose several mechanisms linking 3,4-methylenedioxy-methamphetamine use to spontaneous nontraumatic intraorbital hematoma.

The Importance of Early Diagnosis of Retrobulbar Hemorrhage.

Midface fractures usually affect the orbital cavity. This trauma may result in severe and rare consequences such as retrobulbar hemorrhage. This condition requires immediate diagnosis and early intervention to avoid blindness. The treatment usually requires evaluation of an oral and maxillofacial surgeon. This patient report aims to describe a facial trauma resulting in blindness after 4 days. An 83-year-old woman fell and hit her face on the floor. The initial evaluation only found a contusion on her left orbit, and an ophthalmologic examination was not made. After 72 hours, the patient searched for the oral and maxillofacial surgeon, showing blindness of her left eye. Despite the treatment, the vision was not recovered. Blindness can become irreversible 90 minutes after trauma, and this condition must be treated as an emergency.

Retrobulbar hemorrhage during or after endonasal or periorbital surgery: what to do, when and how to do it.

Retrobulbar hemorrhage (RBH) is an uncommon complication of endoscopic sinus surgery or periorbital surgery consisting in an accumulation of blood within the orbit posteriorly to the eyeball. It must be treated within 90-100 minutes to avoid irreversible visual loss. The present paper tries to pinpoint the key steps in diagnosis and treatment of RBM.On the wake of a new case, the authors review and update their clinical experience and propose a step-by-step protocol to diagnose and to treat RBH developing under different circumstances: during endoscopic sinus surgery, during periorbital surgery, immediately after the surgery, in the awakening room, or postoperatively in the ward.A therapeutic ladder is proposed that starts with lateral canthotomy and inferior cantholysis and progresses to a lower lid transconjunctival incision with retrocaruncular extension.Based on our experience, the proposed guidelines are effective in diagnosing and treating RBH. They allow to preserve vision and minimize reliquates of this rare and dangerous surgical emergency.

The estimation of postoperative bleeding after reduction of blowout fracture: the effectiveness of negative-pressure drainage system.

BACKGROUND: Retrobulbar hemorrhage is a rare complication of midface injury, blepharoplasty, facial fracture surgery, periorbital surgery, and circumbulbar anesthesia. The incidence of postoperative retrobulbar hemorrhage is 0.3% to 4% after the reduction of facial bone fracture. The purpose of this study was to estimate the postoperative bleeding after the reduction of a blowout fracture and to demonstrate the effectiveness of a negative-pressure drainage system with a scalp vein set tube. METHODS: From January 2006 to July 2013, we handled a total of 1491 cases of blowout fractures. Two of them (0.13%) were diagnosed as retrobulbar hematoma in 2011. After experiencing 2 cases of retrobulbar hematoma, we have been routinely using a scalp vein set tube as a negative-pressure drainage system to check the postoperative blood volume. RESULTS: From January 2012 to July 2013, a total of 131 patients underwent blowout fracture repair and experienced application of a negative-pressure drainage system. Their mean total drained amount was 12.6 mL; maximum amount was 47.5 mL in the 2 days after the surgery. The maximum drained amount was 41.7 mL on the day of the surgery. All the patients had no cardinal signs or symptoms of retrobulbar hematoma and no complications. CONCLUSIONS: Retrobulbar hematoma is a rare but critical surgical complication that leads to permanent visual loss. Considering the limited orbital cavity and postoperative edema, the volume of postoperative bleeding is thought to be enough to compress the optic nerve if the blood is not drained. Thus, we recommended a simple negative-pressure drainage system to prevent retrobulbar hematoma.

Delayed periocular hemorrhage after upper blepharoplasty.

Periocular and orbital hemorrhage are rare complications of blepharoplasty, with a reported incidence of 0.055%. These complications are even less common more than 48 h after surgery. The authors report 2 cases of postoperative hemorrhage 5 and 8 days following uncomplicated upper blepharoplasty in which the initiating factor seems to have been uncontrolled hypertension. Details of the presentation, management and follow-up of each patient are described. These cases serve as an important reminder that patients must be appropriately counseled regarding the postoperative implications of their systemic conditions.

Incidence of retrobulbar hemorrhage in the emergency department.

Retrobulbar hemorrhage is a rare but potentially devastating complication of midface trauma. Management of this entity requires prompt diagnosis and medical and surgical interventions. The incidence of retrobulbar hemorrhage has been cited to be lower than 1%; however, despite a low rate of occurrence, lack of immediate care can lead to major morbidity for the patient. This report presents a retrospective evaluation of the incidence and management of post-traumatic retrobulbar bleed in the emergency department by an oral and maxillofacial surgery service at a tertiary care trauma center.

Orbital vicarious menstruation.

A 31-year-old African-American woman with a medical history of well-controlled hypertension sought treatment for recurrent, monthly, unilateral orbital and subconjunctival hemorrhage for 1 year. The episodes were cyclical and coincided with the timing of her menstrual cycle. Examination findings included right periorbital fullness and subconjunctival hemorrhage. Extensive serologic and radiographic workup ruled out other potential causes of recurrent orbital hemorrhage. The patient was diagnosed with orbital vicarious menstruation and treated with oral contraceptive pills, with marked clinical improvement.

Cirrhosis-related coagulopathy resulting in disseminated intravascular coagulation and spontaneous orbital hemorrhages.

A 33-year-old patient presented to our Emergency Department (ED) with left-sided eyelid ecchymoses and edema. A CT scan of the orbits demonstrated a left retrobulbar hemorrhage, prompting an ophthalmology consultation. Upon examination, the patient reported worsening eye pain and decreasing vision in the left eye. Despite aggressive management with superior and inferior lateral canthotomy/cantholysis with placement of an orbital drain, visual loss occurred, and the patient ultimately expired from her systemic condition. Coagulopathy from liver disease resulting in systemic hemorrhage is commonly seen. Orbital hemorrhage in this setting requires emergent diagnosis and management to prevent irreversible compressive optic neuropathy.

Spontaneous subperiosteal orbital hematoma as initial presentation of metastatic lung adenocarcinoma to the skull: case report.

INTRODUCTION: Subperiosteal orbital hematoma is a rare occurrence, typically developing as a result of orbital trauma. The spontaneous formation of a subperiosteal orbital hematoma (sSOH) may also occur but is less frequent. To date there has been no documented cases of sSOH as the initial presentation of an unknown metastatic neoplasm to the skull. We provide a case of a woman with unknown lung adenocarcinoma that metastasized to the skull which caused the formation of a sSOH resulting in orbital compression syndrome. CASE REPORT: A 57-year-old female presented with double vision, retro-orbital right eye pain, and vision loss in the right eye. A magnetic resonance imaging revealed a right orbital compressive lesion with an adjacent supraorbital skull lesion and separate left frontal skull lesion. Intra-operative findings along with post-operative immunohistochemistry staining revealed sSOH resulting from a metastatic lung adenocarcinoma to the skull. Further metastatic work up also revealed an occult lung mass and multiple spinal lesions. CONCLUSION: Differential diagnosis of etiologies causing the formation of sSOH in an adult without history of trauma should include metastatic neoplasm to the skull and warrants metastatic workup. Treatment options of sSOH have included observation with spontaneous resolution; however, we opted for surgical decompression of the eye and biopsy of the skull mass.

Spontaneous subperiosteal orbital hemorrhage.

Subperiosteal orbital hemorrhage typically results from trauma. Spontaneous subperiosteal orbital hemorrhage (SSOH) is rare and has been reported with sudden elevation of cranial venous pressure, bleeding diathesis, and sinusitis. This article presents a series of 9 patients (11 orbits) with SSOH and review the associated systemic conditions. 10 out of 11 orbits (91%) underwent surgical intervention due to advanced orbital signs or poor vision.

Spontaneous subperiosteal hematoma precipitated by anxiety attack.

A 60-year-old woman presented with diplopia and left periorbital edema and pressure, which developed during an anxiety attack the previous day. Examination revealed left inferotemporal globe dystopia, periorbital edema, ecchymosis, and limitation in supraduction. Orbital MRI confirmed the diagnosis of a superior subperiosteal orbital hematoma. The patient's signs and symptoms rapidly resolved with administration of oral corticosteroids. The patient remains asymptomatic with complete resolution of orbital signs at 3-month follow-up. Subperiosteal orbital hematoma (SOH) is a rare condition in which blood accumulates between the bony orbit and separated periosteum, and is often due to blunt head trauma. Non-traumatic SOH (NTSOH) is exceedingly rare and usually associated with known coagulopathies or tendency to bleed. However, few cases of spontaneous NTSOH have been reported without any such predisposition and are thought to be caused by sudden elevations in intrathoracic and intracranial venous pressure such as vomiting, coughing, SCUBA diving, weight lifting and labor. We herein describe the presentation, radiography and outcome of a unique case of spontaneous NTSOH following an anxiety attack.