Emergency surgical decompression of the orbit may rescue impaired vision even in a patient presenting late with a retrobulbar haematoma: A case report from rural southwestern Uganda.

Retrobulbar haematoma is a rare emergency that can potentially lead to blindness. Common causes include facial trauma and surgery. Timely surgical evacuation of the haematoma improves visual outcomes. In rural communities, patients often present to hospital after many hours and this increases the risk of poor visual outcomes. Radiological evaluation which is often not available in rural communities, results in further delay in surgical treatment. This case report highlights the need for urgent surgical intervention over radiological evaluation in patients with retrobulbar haematoma and orbital compartment syndrome.

Orbital compartment syndrome secondary to retrobulbar hematoma after infratrochlear nerve block for nasolacrimal probing.

After infratrochlear nerve block for nasolacrimal probing, sudden vision loss, proptosis, pain, loss of light reflexes, and a total limitation of ocular movement was observed in a 71-year-old female patient. She was diagnosed with retrobulbar hemorrhage and orbital compartment syndrome (OCS). Lateral canthotomy, cantholysis, and medial orbitotomy were performed on the patient. She was not taking any oral anticoagulant medication and did not have any disease other than hypothyroidism and systemic hy-pertension. All the clinical findings returned to normal right after the intervention except mild ptosis (~1 mm), which persisted for 2 months. All patients scheduled for periocular anesthesia should be questioned about using oral anticoagulant medications, and the possibility of serious complications should be kept in mind even for patients without any risk factors. Patients with OCS secondary to retrobulbar hemorrhage should be surgically managed within the critical window (90 min) to prevent any irrevers-ible optic nerve injury.

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 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.

Acute retrobulbar hemorrhage after tooth extraction: Case report and treatment of a rare condition.

Retrobulbar hemorrhage (RBH) refers to hemorrhage within the bony orbital cavity and most commonly results from periorbital surgery or trauma. RBH following tooth extraction is a rare occurrence. Patients with RBH will endorse symptoms of periorbital pain, double vision, or vision loss, and present with evidence of proptosis, chemosis, or subconjunctival hemorrhage. Irreversible vision loss may occur if orbital compartment syndrome (OCS) results in the setting of RBH and is not expediently treated. Herein we present a case of a 72-year-old female who developed a RBH and OCS immediately after routine molar tooth extraction. Emergent treatment by the oral surgeon with a lateral canthotomy and inferior cantholysis led to full visual recovery. Dentists and oral surgeons should be aware of this potential rare vision-threatening complication of atraumatic tooth extraction and educated on the technique of decompressive lateral canthotomy and cantholysis.

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.

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.

Traumatic Globe Subluxation Accompanied by Traumatic Optic Neuropathy.

A 52-year-old, alcohol-intoxicated woman suffered periorbital trauma to the left eye and presented to the emergency department with proptosis and complaints of decreased vision in the left eye. Physical examination revealed loss of light perception (LP), relative afferent pupillary defect (RAPD), pupil dilatation, and corneal epithelial defect of the left eye. In addition, the fundus of the left eye was not easily visible due to severe corneal abrasion and edema, but there was no retinal detachment or vitreous hemorrhage on B-scan ultrasonography. Hertel exophthalmometric values differed by 7 mm between the eyes and measured 13 mm in the right eye and 20 mm in the left eye. In addition, she had severely limited left eye movement in all directions. Computerized tomography (CT) imaging of the orbit showed that the left optic nerve extended 15 mm further than the optic nerve of the right eye and retrobulbar hemorrhage of the left eye. The patient underwent emergency lateral canthotomy, cantholysis, and conjunctival incision to release the optic nerve extension and reduce the eyeball subluxation of the left eye. An intraoperative examination demonstrated that all extraocular muscles of the left eye were intact. The left eyeball returned to its normal position after surgery. Two days after surgery, proptosis of the left eye improved significantly, and there was no difference in Hertel exophthalmometric values between the eyes, both eyes measured 13 mm. However, the patient continued to suffer LP, RAPD, and pupil dilatation of the left eye.

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.

Development of a novel simulation-based task trainer for management of retrobulbar hematoma.

BACKGROUND: Retrobulbar hematoma (RH) is a rare but devastating complication of sinus surgery. It is treated initially with a lateral canthotomy and cantholysis at the bedside. Due to the high stakes and urgency of this complication, teaching this in the clinical setting is difficult. The objective of this study was to develop a cadaveric model for addressing this problem. METHODS: A fresh-frozen human cadaveric model of RH was created using a Foley catheter to simulate elevated intraocular pressure. Residents who participated in an emergencies in otolaryngology-head & neck surgery "boot camp" were included in the study. A survey measuring confidence levels in performing lateral canthotomy and cantholysis was administered. After completing the skill station, a postintervention survey was administered to assess the confidence of the learner as well as fidelity and usefulness of the task trainer. RESULTS: Thirty-three residents participated in the boot camp. Residents rated their confidence preintervention at 1.3/5, which suggests the majority were unable to perform the procedure. After using the model, residents rated their confidence at 3.5/5, which falls between basic knowledge and reasonably confident; this improvement achieved statistical significance (p < 0.0001). The fidelity of the model was rated 3.9/5; a score of 4 is defined as realistic. The residents rated the usefulness of the model as 4.7; a score of 5 is defined as very useful. CONCLUSION: A cadaveric model of RH was successfully developed. This novel simulator was perceived to be useful, realistic, and effective by junior residents.

Visual Outcomes of Patients With Retrobulbar Hemorrhage Undergoing Lateral Canthotomy and Cantholysis.

PURPOSE: Evaluate visual outcomes in relation to time from injury to intervention in patients who undergo lateral canthotomy with cantholysis (LCC) for retrobulbar hemorrhage (RBH). METHODS: Retrospective study of patients with orbital compartment syndrome (OCS) secondary to RBH who underwent LCC. OCS due to RBH was defined by a combination of decreased vision, proptosis, resistance to retropulsion, increased intraocular pressure, and relative afferent pupillary defect. Time from injury to intervention and change in visual acuity were calculated, with regression analysis identifying predictors of vision recovery. RESULTS: Fifteen participants were included. Three (20%) participants presented with no light perception, 7 (47%) with count fingers (CF) to light perception, and 5 (33%) with better than count fingers vision. All 5 participants who had LCC within 3 hours (twice the standard 90 minutes) gained some vision, and 6 of 10 participants who had LCC after 3 hours recovered some vision. The latest intervention with visual acuity improvement was performed 9 hours postinjury. Of 3 participants who presented with no light perception vision, 1 regained vision to 20/40 (intervention 1.7 hours postinjury), and 2 did not regain any vision (interventions at 5 and 8.7 hours postinjury). Duration from injury to intervention was associated with decreased amount of vision recovery (P = 0.03). CONCLUSIONS: Increased time to intervention with LCC was associated with less vision recovery after OCS from RBH. However, over half of participants with intervention more than 90 minutes after injury still showed visual acuity improvement. The authors recommend LCC in all patients who present with OCS regardless of the time since injury.Patients with orbital compartment syndrome may see visual recovery after lateral canthotomy and cantholysis, even if performed outside of the previously accepted 3-hour window.

Retrobulbar haematoma in the era of anticoagulants.

AIM: The present retrospective study aimed to evaluate the frequency and distribution of retrobulbar haematoma (RBH) among 26 patients (12 male/14 female) who had suffered maxillofacial trauma/surgery, with special focus on anticoagulants, causes of accidents, treatment, and outcome. METHODS: Patient ages ranged from 8 to 94 years, with a mean of 65 years. Among all patients, 43% had received anticoagulant therapy at admission; 92.3% had a previous history of maxillofacial trauma. RESULTS: The most frequent cause of RBH were falls (65.4%), and three patients experienced RBH postoperatively after treatment using polydioxanone foil. Postoperatively (after RBH relief), 33.3% of the patients reported persistent complete visual loss; of these patients, 29% had received anticoagulation therapy, and the oral anticoagulant intake was not documented in further 29% of the patients. CONCLUSION: Awareness of this pathologic process is crucial for preventing permanent loss of vision via early diagnosis and adequate therapy. With increasing age, patients are more likely to receive an anticoagulant, which leads to a higher risk of RBH. Because falling was the most frequent cause of RBH in our patient population and increases in frequency with increasing age, fall prevention is crucial.

Paracanthal "One-Snip" Decompression in a Cadaver Model of Retrobulbar Hemorrhage.

PURPOSE: The authors assess the effectiveness of a modified paracanthal or "one-snip" procedure compared with the traditional lateral canthotomy and inferior cantholysis in the reduction of intraocular pressure (IOP) and proptosis in a human cadaveric model of retrobulbar hemorrhage. METHODS: This study comprised a comparative interventional study in a cadaveric model of retrobulbar hemorrhage. Six orbits of 3 fresh cadavers were included in the study. Baseline measurements of IOP and proptosis were recorded for all 6 orbits before and after simulation of retrobulbar hemorrhage as previously described. Right orbits (n = 3) underwent traditional lateral canthotomy and inferior cantholysis. Left orbits (n = 3) underwent modified paracanthal or "one-snip" procedure. The primary outcome measures were reduction in IOP and proptosis between the 2 techniques. RESULTS: Following lateral canthotomy and inferior cantholysis of each right orbit, the average IOP dropped to 14 mm Hg (range of 11-18 mm Hg), corresponding to a mean decrease of 32 mm Hg. Following the "one-snip" procedure of each left orbit, the average IOP dropped to 19 mm Hg with a range of 16 to 23 mm Hg, corresponding to a mean decrease of 22 mm Hg. There was no statistically significant difference in IOP reduction (p = 0.36) or proptosis reduction (p = 0.23) between the 2 treatment groups. CONCLUSIONS: Compared with traditional lateral canthotomy xand inferior cantholysis, the modified paracanthal or "one-snip" procedure is effective for IOP reduction and led to mild improvement of proptosis in a cadaveric model of retrobulbar hemorrhage. The authors hope this study helps improve orbital compartment syndrome outcomes by providing an option that more providers will feel comfortable performing and therefore decreasing time to surgical decompression.

Fenestration of Solid Orbital Implants: Reducing Retrobulbar Hematoma Rate.

PURPOSE: Retrobulbar hematoma is an uncommon but potentially devastating complication following repair of orbital fractures. Since 2007, the senior author routinely fenestrates the solid porous polyethylene implants commonly used for orbital reconstruction. The perforated implant may facilitate drainage of postoperative bleeding and may potentially reduce the risk of retrobulbar hematoma. This study examines the rates of retrobulbar hematoma in patients who underwent orbital fracture reconstruction with placement of fenestrated or nonfenestrated implants. METHODS: A retrospective chart review of patients with orbital fracture reconstruction using an implant performed by the senior author between 2006 and 2016 was conducted. Data collected included age, sex, implant type, and presence of retrobulbar hematoma. RESULTS: One hundred four patients were included in the study. One patient who was treated with a nonperforated implant was found to have a postoperative retrobulbar hematoma. The retrobulbar hematoma did not cause visual changes or increased intraocular pressure, so the patient was observed and did not undergo any surgical intervention. The hematoma resolved spontaneously without further sequela. No patients with fenestrated implants had a retrobulbar hematoma. CONCLUSIONS: Fenestration of solid implants used in orbital floor reconstruction is simple and easy to perform, and may reduce the incidence of postoperative retrobulbar hematoma.

Dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia.

PURPOSE: To evaluate the prevalence of dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia. SETTING: Department of Ophthalmology, Ludwig-Maximilans Universität, München, Germany. DESIGN: Retrospective study. METHODS: Two groups of patients were screened retrospectively over a 5-year period for the inclusion criterion of severe retrobulbar hematoma after retrobulbar or parabulbar injection. The first group consisted of emergency cases referred to the clinic. A second group of patients had received retrobulbar block at the hospital. All cases were collected and screened for the presence of antiplatelet therapy. RESULTS: Among roughly 160 000 patient records screened, 3 patients with grade IV retrobulbar hematoma were identified. Two of these patients were taking dual antiplatelet medications and 2 were on anticoagulation therapy during the time of retrobulbar or peribulbar anesthesia. None of the cases showed single medication platelet inhibition. The visual acuity of all patients stayed low at the 6-month follow-up (1.2 logMAR in 1 patient and no light perception in 2 patients). CONCLUSIONS: Retrobulbar hematoma is a rare but severe complication of retrobulbar anesthesia. With the high prevalence of dual platelet inhibition found in these cases, a prospective controlled trial seems unethical. In these high-risk patients, surgery should be performed under topical anesthesia if possible or general anesthesia if necessary. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

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.

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.

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.