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.

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.

Emergency Treatment of Ocular Trauma.

Injuries to the eye and its adnexa are common in head and neck trauma centers. An ophthalmologist experienced in ocular traumatology is not always available. Therefore, every emergency physician should be familiar with the basic evaluation, triage, and management of ocular trauma. Above all, the identification of a need for immediate treatment should be implemented in the algorithm of an emergency room, especially in a head and neck trauma center, to reduce the risk of a devastating loss of vision. This article formulates the different types of ocular trauma and their required first-line therapy.

Postoperative visual loss due to complicated mediastinal dissection and haemorrhagic shock treatment during cardiac surgery.

We report the case of a patient who underwent third time revision of double heart valve replacement. Mediastinal dissection for right atrium cannulation was complicated by laceration of the superior vena cava; this required temporary rescue clamping of the vessel. The patient suffered complete visual loss related to bilateral retrobulbar haematoma. Acute elevation of superior vena cava pressure due to vascular clamping and administration of large amounts of fluid through the central venous jugular catheter could have caused the postoperative visual loss.

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.

Visual loss after blepharoplasty: incidence, management, and preventive measures.

BACKGROUND: Although rare, instances of visual loss after cosmetic blepharoplasty have been previously reported in the literature. OBJECTIVES: The goal of this study is to summarize the existing literature and report the results of a physician survey in order to provide appropriate guidelines for preventing, diagnosing, and treating this unfortunate complication. METHODS: A 13-question survey was sent to all members of the American Society for Aesthetic Plastic Surgery (ASAPS) and the British Association of Aesthetic Plastic Surgery (BAAPS). Surgeons were queried about their number of years in surgical practice, their average annual caseload of blepharoplasties, and the number of cases of visual loss. The survey also contained questions about the type of anesthesia administered, surgical technique, the presence of risk factors or comorbidities in patients, symptoms, time of presentation, management, and final outcome. RESULTS: A total of 648 responses were received from ASAPS members and 72 from BAAPS members. The overall number of blepharoplasties reported by these respondents was 752,816. Thirty-nine cases of visual loss were reported: 25 permanent and 14 temporary. According to this, the overall incidence of visual loss following blepharoplasty was calculated at 0.0052% (five of 100,000 cases, or one in 20,000). Permanent visual loss was calculated at 0.0033% (three in 100,000, or one in 30,000) and temporary visual loss at 0.0019% (two in 100,000, or one in 50,000). The most common symptoms in affected patients were pain and pressure. Development of symptoms was reported to occur within the first 24 hours, with two peaks: intraoperative to one postoperative hour, and six to 12 postoperative hours. Hypertension was the most common risk factor for postoperative visual loss. Retrobulbar hemorrhage was reported to be the main cause of blindness. The most common management technique reported was orbital decompression, followed by steroids and canthotomy. CONCLUSIONS: According to this study, blindness after blepharoplasty is a rare event. However, every step should be taken to prevent it. Prevention should begin in the preoperative period and should continue intraoperatively and postoperatively. Once the diagnosis of impending visual loss is made, it should be treated as a true surgical emergency, since early treatment has proven beneficial.

When is a retrobulbar haemorrhage not a retrobulbar haemorrhage?

Retrobulbar haemorrhage (RBH) is a well described condition which is said to be a common cause of acute proptosis following trauma, but the evidence for this is not strong. The authors reviewed 186 publications on the subject, finding 82 cases of RBH related to trauma. This analysis suggests that in over half of the cases described, RBH was never proven conclusively. In the authors' experience RBH is not a common cause of acute proptosis following trauma and other causes need to be considered if patients are to be managed appropriately.

Acute proptosis in trauma: retrobulbar hemorrhage or orbital compartment syndrome--does it really matter?

PURPOSE: To review the nature and outcomes of acute severe proptosis in patients after craniofacial trauma, over a 6-year period. PATIENTS AND METHODS: These were identified prospectively. The mechanism of injury, nature of the proptosis, and visual outcomes in each case were reviewed. Review of the literature was undertaken. RESULTS: In all cases proptosis, was secondary to retrobulbar edema and not hemorrhage. CONCLUSIONS: Many cases of "retrobulbar hemorrhage" may, in fact, be secondary to edema. This has significant implications when managing the proptosed eye on an emergent basis. Possible reasons for poor outcomes are discussed. A number of unanswered questions arise from this review.

Mucormycoses: serious complication of high-dose corticosteroid therapy for traumatic optic neuropathy.

Mucormycosis is harmless to a healthy person, but can cause opportunistic infections in immunocompromised patients, and once it has invaded internal organs is frequently fatal. Traumatic optic neuropathy is a rare complication of maxillofacial trauma. Management is controversial, and there are no treatment guidelines in the literature. The main methods of treatment of this condition employed today are high-dose corticosteroids and surgical optic nerve decompression, either alone or in combination. In this case, the patient was in good health, but received high-dose corticosteroids for 2 weeks, which temporarily diminished immune response and permitted the development of mucormycosis.

Blindness following retrobulbar haemorrhage--it can be prevented.

Delay in diagnosis and treatment of an elderly woman with a malar fracture that caused retrobulbar haemorrhage resulted in complete loss of vision in the right eye.

Visual loss following dacryocystectomy.

Dacryocystectomy is the surgery of choice for elderly patients with chronic dacryocystitis with a fibrotic sac. Although a simple procedure, it can cause serious complications (however rare) such as visual impairment. A 65-year-old woman who underwent bilateral dacryocystectomy is described. On the first postoperative day, she complained of pain in her left eye. Her visual acuity was light perception in the left eye. Computed tomography scan of the orbit revealed a retrobulbar hematoma on the left eye. The hematoma was drained, but the patient did not regain vision. A rare complication of visual loss following dacryocystectomy is described.

Retrobulbar hemorrhage nine days after cosmetic blepharoplasty resulting in permanent visual loss.

A healthy 45-year-old man had a retrobulbar hemorrhage 9 days after cosmetic upper eyelid blepharoplasty that resulted in permanent visual loss. After performing a left lateral canthotomy and cantholysis, intraocular pressure returned to normal and vision improved from no light perception to 20/40; however, the patient did have permanent visual field loss. To our knowledge, this is the longest period of time after blepharoplasty that a retrobulbar hemorrhage occurred. Ophthalmologists should have a heightened level of suspicion 1 to 2 weeks after surgery.

Diagnosis and treatment of orbit posttraumatic subperiosteal hemorrhage in a child, associated with a subdural intracranial hemorrhage.

We describe a rare case of traumatic subperiosteal orbital hematoma in a child, with intracranial hemorrhagic complication. Subperiosteal hematoma are the more infrequent occurrences among intraorbital hemorrhagic lesions and can be also associated with intracranial extradural hematoma in patients with orbital roof fracture. Here, we describe a case without roof fracture but with a never-before described intracranial subdural hematoma. The patient underwent computed tomography and magnetic resonance imaging, in an acute state, and later, a radiologic diagnosis of percutaneous drainage of the hematoma was mad. MRI was more sensitive and specific in the evaluation of the intracranial and intraorbital complication.

Orbital and adnexal trauma associated with open-globe injuries.

PURPOSE: To describe the incidence and patterns of orbital and adnexal injuries in patients with open-globe injuries. METHODS: Charts of 300 consecutive patients with open-globe injuries presenting to the Massachusetts Eye and Ear Infirmary were retrospectively reviewed. The data were analyzed with respect to the type of open globe (penetrating, perforating, or rupture) and location (zone) of globe injury. Each of these subgroups was then evaluated for the absence (group 1) or presence (group 2) of coexisting orbital and/or adnexal injury. Visual acuity at presentation was compared between the two groups. RESULTS: Orbital and adnexal injuries were present in 25.7% of patients with open globes. The most common concurrent injuries were lacerations of the eyelid, orbital fracture, and retrobulbar hemorrhage. The mechanisms of globe injury differed significantly between groups 1 and 2. Penetrating injuries accounted for 82.1% of group 1 but only 49.3% of group 2 patients, whereas rupture occurred more frequently in group 2 (48.1%) than in group 1 (17.0%) patients. Orbital and adnexal injuries were associated with poorer visual acuity at presentation, probably because of the high incidence of posterior globe injuries in these patients. CONCLUSIONS: Orbital and adnexal injuries were observed in 25.7% of patients who sustained trauma that resulted in open globes. Concurrent injury to these extraocular structures is associated with worse visual acuity at presentation and an increased likelihood of posterior globe injuries.

Quantification of the neurodegenerative impact on the visual system following sudden retrobulbar expanding lesions - an experimental model.

INTRODUCTION: Afferent disorders of the visual system are a potential consequence following orbital trauma. The aim of this study was to investigate the tolerance of neurons in the retinal ganglion cell layer to acute expanding retrobulbar lesions. MATERIAL AND METHODS: In 42 male albino rats, intraorbital haemorrhage was simulated by transconjunctival insertion of a retrobulbar micro-balloon (filling volume 0.2-0.5 ml, duration of lesion 60 or 90 min). Neurodegeneration in the retinal ganglion cell layer was investigated by measuring the mean total neuron number and the mean neuron size. RESULTS: Increased retrobulbar volumes of 0.3 ml for 60 min led to a decrease in a number of neurons by 14.5% and in size of the neurons by 1.7%. Prolongation of the trauma to 90 min resulted in a decrease in number of neurons by 48.3% and in reduction of size of neurons by 22.1%. In contrast, a retrobulbar filling volume of 0.5 ml for 60 min resulted in a decrease in number of neurons by 11.4% and in size of neurons by 6.7%. CONCLUSION: The duration of a retrobulbar lesion leading to subsequent retinal ischaemia seems to be more important for neuron survival than the exerted pressure (once it is greater than a critical point for producing retinal ischaemia). The results strengthen the need for emergency treatment in cases of retrobulbar haemorrhage.

[Anterior ischemic optic neuropathy secondary to retrobulbar hematoma]. / Neuropatie optica ischemica anterioara secundara hematomului retrobulbar.

Two clinical cases are displayed, age over 70, with multiple vascular risk factors; following the retrobulbar injection performed for cataract surgery, retrobulbar hematoma and ischemic anterior neuropathy developed as complications. Pathogenesis of the optic ischemic anterior neuropathy may be explained by changes of a precarious hemodynamic balance and witch was previously settled, due to mechanic compression and increase of the intraocular pressure, which lead to the decrease of the blood pressure and implicitly to the development of optic neuropathy.

Non-traumatic orbital haemorrhage.

PURPOSE: To establish the incidence of underlying orbital vascular anomalies, the presence of systemic associations and predisposing factors, the natural history and appropriate management of patients with non-traumatic orbital haemorrhage presenting in an orbital clinic. METHODS: The records of 115 patients with a diagnosis of non-traumatic orbital haemorrhage were reviewed with regard to clinical findings, investigations, management and outcome. RESULTS: Associated orbital vascular malformations were present in 104 patients (90%). Thirteen (11%) had additional or other predisposing factors (childbirth, prolonged headstands, hypertension or coagulopathies). Six patients (5%) had no predisposing factor. Acute onset painful proptosis, associated with lid swelling or a mass, was the most common presentation. Visual acuity was reduced in 37 patients (32%) at presentation. Excluding eight patients (7%) who underwent surgery for optic nerve compression, spontaneous resolution of the haemorrhage was complete in 62%, partial in 27%, while 4% had no resolution. Final visual acuity was reduced in 23 patients (20%). CONCLUSION: The majority of bleeds are associated with some form of orbital vascular anomaly. Where no such anomaly can be demonstrated a search for an underlying systemic cause should be performed. Haemorrhages in the young were usually localized whereas those in older patients were diffuse. Orbital imaging, with a combination of computed tomography and magnetic resonance imaging, was helpful in the assessment of these lesions. Most bleeds are venous and self-limiting. Surgical intervention was rarely necessary and should be confined to those with optic nerve compromise or a localized lesion which persists.

Vascular hamartoma of the orbit.

The aim of this presentation is to report a combined form of vascular malformation of the orbit. A 2-year-old girl had a four-month history of severe proptosis in the right eye. The patient had intermittent proptosis in association with a common cold. The globe was displaced downward and extraocular motility was markedly limited. Multiple intraconal and some extraconal cysts were removed with transcutaneous transseptal anterior orbitotomy. Histological examination showed several characteristics of vascular anomaly. There were malformatively dilated veins intermingled with dilated lymphatic channels, focal cavernous and capillary hemangiomatous features. This combined form of vascular anomaly can be presented as a venous lymphatic malformation associated with hemangiomatous features.

Lateral canthotomy and inferior cantholysis: an effective method of urgent orbital decompression for sight threatening acute retrobulbar haemorrhage.

Retrobulbar haemorrhage (RBH) occurs in a variety of situations. It can complicate facial fractures, orbital surgery and retrobulbar injections and can occur spontaneously. It is relatively uncommon and sight-threatening RBH is even less common. If not detected early enough it can lead to devastating loss of vision. We have collected five cases of acute RBH, following trauma, associated with a profound reduction in vision. In each case a permanent loss of vision was avoided using a lateral canthotomy and inferior cantholysis approach to obtain urgent orbital decompression.