Successful Management of a Spontaneous Retrobulbar Hematoma After Heart Transplantation. A Case Report.

CASE DESCRIPTION: We present a case of a 65-year-old patient who underwent heart transplantation. After the surgery, left proptosis, conjunctival chemosis, and ipsilateral palpebral ecchymosis were found while he was still intubated. A retrobulbar hematoma was suspected, confirmed by a computed tomography scan. Initially, expectant management was considered, but with the appearance of an afferent pupillary defect, the patient underwent orbital decompression and posterior collection drainage, which prevented visual impairment. CONCLUSION AND IMPORTANCE: Spontaneous retrobulbar hematoma after heart transplantation is a rare condition that risks vision. We intend to discuss the importance of postoperative ophthalmologic examination after heart transplantation in intubated patients for early diagnosis and rapid treatment. Spontaneous retrobulbar hematoma (SRH) after heart transplantation is an exceptional condition that risks vision. Bleeding in the retrobulbar space provokes an anterior ocular displacement, extending the vessels and the optic nerve, which can generate ischemic neuropathy and, finally, a loss of vision [1]. A retrobulbar hematoma is usually associated with trauma or eye surgery. Though, in non-traumatic cases, the underlying cause is not evident. An adequate ophthalmologic examination is usually not performed in complex surgeries like heart transplantation. However, this simple measure can prevent permanent vision loss. Non-traumatic risk factors should also be considered, which include vascular malformations, bleeding disorders, use of anticoagulants, and increased central venous pressure usually triggered by a Valsalva maneuver [2]. The clinical presentation of SRH consists of ocular pain, decreased visual acuity, conjunctival chemosis, proptosis, abnormal extraocular movements, and elevated intraocular pressure (IOP). Its diagnosis is often clinical; however, it can be confirmed with computed tomography or magnetic resonance imaging. Treatment aims to reduce IOP with surgical decompression or pharmacologic measures [2]. In the reviewed literature, less than 5 spontaneous ocular hemorrhages related to cardiac surgery have been reported [3-6], of which only one is related to heart transplantation [3]. A clinical challenge of an SRH after heart transplantation is presented below. Surgical management was performed with a favorable result.

A Recurrent Orbital Hemorrhage in an Older Adult.

An adult patient in their 70s presented with unilateral painless proptosis and blurred vision of the right eye that resolved with corticosteroid treatment. Magnetic resonance imaging revealed a retrobulbar hemorrhage. Six months later, the hemorrhage and proptosis recurred, with incomplete resolution despite similar treatment. What would you do?

Spontaneous Retrobulbar Hemorrhage in a Previously Healthy Infant.

Spontaneous retrobulbar hemorrhage is a rare yet vision-threatening condition. We reported a 5-month-old male infant with sudden onset of left eye proptosis with no prior history of getting vitamin K injection after birth. Head computed tomography scan revealed retrobulbar and intracranial hemorrhages. Laboratory results showed anemia, prolonged prothrombin and activated partial thromboplastin time, supporting the diagnosis of vitamin K deficiency bleeding. After the bleeding and clotting profile were stabilized, lateral canthotomy and cantholysis; and drainage following orbital decompression were successfully performed, yielded in a completely resolved proptosis. The right timing for surgery with the goal of releasing intraorbital pressure represent the merit of this paper. Our case also led to a crucial emphasis on vitamin K prophylaxis at birth.

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.

First description of a retrobulbar haemorrhage in a paediatric patient.

An 8-year-old girl presented to the paediatric emergency department 3 days after left orbital exploration for an orbital floor fracture. She had been vomiting for the last 24 hours and her mother's primary reason for presentation was that she was unable to keep down any analgesia . She reported pain in that eye and was unable to see. On examination, the eye was swollen and had yellow discharge. A CT scan was performed to rule out an infective collection and, unexpectedly, showed a retrobulbar haematoma. Ophthalmology was called and she was immediately taken to theatre for a lateral canthotomy for decompression. Fortunately, she regained her vision following this but, had the retrobulbar haematoma not been recognised urgently, she may have lost her vision permanently in that eye. Retrobulbar haematomas are quite rare in children this age and there is very little published literature on this topic.

Volumetric Analysis and Clinical Outcome in 54 Patients with Retrobulbar Hematoma.

PURPOSE: Retrobulbar hematoma (RBH) is a rare but serious vision threatening emergency. We analyze the relationship between hematoma volume, visual impairment and outcome. METHODS: Fifty-four patients with RBH receiving orbital decompression were retrospectively included. Volumetric analysis of RBH was performed by semi-automatic segmentation based on preoperative CT scans using ITK-SNAP software. Best corrected visual acuity (BCVA) measurements were obtained and correlated in 2 groups (no light perception (NLP), severe visual impairment) with the hematoma volume. RESULTS: NLP was documented preoperatively in 5/28 and postoperatively in 9/43 patients. Preoperative NLP was significantly associated with a larger hematoma volume (P = .03) and higher hematoma/orbital volume ratio (P = .03). Postoperative severe visual impairment showed significant associations with a larger hematoma volume (P = .02) as well as higher hematoma/orbital volume ratio (P = .02). CONCLUSION: Eyes with severe visual impairment and large hematoma volumes preoperatively are at high risk of permanent vision loss. Hematoma volume calculation might represent an additional prognostic parameter for visual outcome after RBH.

Subperiosteal Orbital Hemorrhage: An Unusual Complication During Labor.

ABSTRACT: Subperiosteal orbital hemorrhage in the postpartum period has been rarely reported. The authors herein present a female patient who developed acute-onset vertical diplopia, proptosis, mild retro-orbital pain, and restriction of upgaze immediately after labor. Neuroimaging revealed a subperiosteal hematoma along the right orbital roof. Diplopia, motility limitation, and retro-orbital pain gradually resolved in the following weeks. Subperiosteal orbital hematomas are a rare complication of labor, with only 12 cases reported so far. They result from straining during labor, which increases central and orbital venous pressure by means of the Valsalva-maneuver. In order to evaluate ocular motility and exclude optic nerve compression, an urgent ophthalmological examination is required.

Severe chemosis and treatment following fronto-orbital advancement surgery for Crouzon syndrome: A case report.

RATIONALE: Crouzon syndrome is a craniofacial malformation caused by premature fusion of fibrous sutures in infants. It is one of the most common craniosynostosis syndromes, and surgery is the only effective treatment for correcting it. Postoperative complications such as encephalocele, infections, hematoma have been reported. We herein report a case of a 62-month-old boy with Crouzon syndrome who underwent fronto-orbital advancing osteotomy, cranial vault remolding, and extensive osteotomy and subsequently developed left proptosis and severe chemosis, these complications are rare and we believe it will be of use to clinicians, physicians, and researchers alike. PATIENT CONCERNS: The patient's skull had been malformed since birth, and he had been experiencing paroxysmal headaches coupled with vomiting for 4 months. Having never received prior treatment, he underwent fronto-orbital advancement at our clinic; afterward, left proptosis and severe chemosis occurred. DIAGNOSIS: The patient was diagnosed with Crouzon syndrome, and the complications included left proptosis and severe chemosis, confirmed by the clinical manifestations, physical examination, and computed tomography (CT). INTERVENTION: We carried out cranial vault remodeling and fronto-orbital advancement. We applied ophthalmic chlortetracycline ointment on the conjunctivae, elevated the patient's head, evacuated the hematoma, and carried out a left blepharorrhaphy. OUTCOMES: The proptosis and chemosis resolved with no recurrence. No other complications occurred during the follow-up period (12 months), and CT scans revealed that the hematoma had disappeared. The calvarial vault reshaping was satisfactorily performed, and the patient's vision was not impaired. LESSONS: Severe proptosis and chemosis are rare complications that can occur after fronto-orbital advancement for Crouzon syndrome. A detailed preoperative examination (including magnetic resonance imaging and CT) is essential for diagnosis. Complete hemostasis, evacuation of hematoma, and placement of a periorbital drainage tube during surgery all contribute to an effective treatment plan. An ophthalmic ointment should be administered, and the patient's head should be elevated during the procedure. Evacuation of retrobulbar epidural hematoma and blepharorrhaphy could also help relieve proptosis and chemosis. Our report describes 2 rare complications associated with the treatment for Crouzon syndrome, and we believe it will be of use to clinicians, physicians, and researchers alike.

Evidence-based algorithm for the management of acute traumatic retrobulbar haemorrhage.

Retrobulbar haemorrhage (RBH) is a potentially blinding consequence of craniofacial trauma, but timely ophthalmic evaluation is difficult to obtain in some settings and clear standards for canthotomy/cantholysis are lacking. We have sought to develop an algorithm to identify vision-threatening traumatic RBH that requires emergent decompression. We retrospectively reviewed 42 consecutive consultations for RBH at a level-one trauma centre. Charts and imaging studies were analysed with attention to mechanism of injury, comorbid trauma, and ophthalmic findings. A total of 22 eyes were observed without intervention, 13 were treated pharmacologically, and seven by emergent canthotomy/cantholysis. No differences in standard trauma metrics were found among these groups. Lid oedema, ecchymosis, chemosis, subconjunctival haemorrhage, and ocular motility also failed to correlate with a need for surgical intervention. "Tight" eyelids (p<0.001), unilateral proptosis (p<0.001), and relative afferent pupillary defect (RAPD; p=0.029), however, all related to a need for canthotomy/cantholysis (Fisher's exact test). Tenting of the globe, which was the only radiographic finding to predict the need for surgery, was seen in just two of the seven cases that required decompression. Many of the traditionally emphasised clinical signs therefore fail to identify cases of RBH that require decompression. Our data support a simple three-factor decision tool. These are: relative proptosis, eyelids that are difficult to open with finger pressure, and presence of an RAPD in the traumatised eye. If all three are noted or if the patient has proptosis and tight lids in the absence of a large preseptal haematoma, he/she is likely to need surgical decompression. Tenting of the globe on computed tomography (CT), while a relatively rare finding, should also alert the physician of the need for intervention.

Ultrasound Identification of Retrobulbar Hematomas by Emergency Physicians in a Cadaveric Model.

INTRODUCTION: Retrobulbar hemorrhage (RBH) is a rare complication of facial trauma that can lead to dangerous orbital compartment pressures and must be rapidly recognized to prevent permanent vision loss. Point-of-care ultrasound (POCUS) offers a rapid modality for evaluating a wide variety of ocular pathologies, and prior case reports demonstrate the ability of clinicians to recognize RBH using ultrasound. This study aimed to assess the ability of clinicians at various stages of training to identify a RBH using POCUS in a cadaveric model. Clinicians also were assessed for self-reported comfort using ultrasound for ocular pathology before and after the study. METHODS: Participants included 17 physicians who evaluated 10 eyes (from five cadavers) that were independently randomized to have either a modeled RBH or no hemorrhage. Participants' final diagnosis of each eye was recorded (RBH present or not), and participants also completed pre- and post-activity surveys. RESULTS: The overall sensitivity and specificity to correctly diagnose retrobulbar fluid was 87% and 88%, respectively. Sensitivity and specificity were higher after excluding clinicians in their early phase of training. Additionally, self-reported comfort level with ocular ultrasound was significantly improved by this activity. CONCLUSION: Emergency physicians at a variety of training levels can correctly identify a cadaveric model of retrobulbar hemorrhage. Use of this cadaveric model can improve exposure of clinicians to the appearance of a rare but vision-threatening ocular pathology such as RBH.

Ocular injury during fetal endoscopy surgery.

A premature infant born at 31 weeks' gestational age was evaluated for periocular laceration and retrobulbar hematoma secondary to injury during a percutaneous fetal procedure. He later developed optic nerve atrophy.

Ocular Injuries: New Strategies In Emergency Department Management.

Ocular injuries are common in the emergency department, and they are the most frequent cause of noncongenital monocular blindness in children and adults. This review provides evidence-based recommendations for the diagnosis, treatment, and disposition of patients with all types of ocular trauma, including pain management, the use of antibiotics, cycloplegics, steroids, antifibrinolytics, and patching. Bedside ocular ultrasound has profoundly expanded diagnostic capability, particularly for the multiply injured patient, and routine management and disposition of patients with corneal abrasions has evolved significantly as well. Diagnosis and management of patients with retrobulbar hemorrhage is discussed in detail, with resources for performing vision-saving lateral canthotomy. Systematic evaluation and management of ocular trauma patients will ensure these patients have the best chance for a favorable final visual outcome.

Acute retrobulbar haemorrhage: An ophthalmologic emergency for the emergency physician.

Acute retrobulbar haemorrhage (ARBH) is a rare ophthalmic emergency observed following blunt eye trauma. Multiple trauma and loss of consciousness can hide symptoms of ARBH. Rapid diagnosis and immediate lateral canthotomy and cantholysis must be performed to prevent permanent visual loss in patients. Medical treatment can be added to surgical therapy. Lateral canthotomy and cantholysis are simple procedures that can be performed by emergency physicians. In this report, it was aimed to present a case with post-traumatic ARBH and provide general knowledge about the diagnosis, follow-up and treatment of ARBH.