Unilateral retrobulbar haemorrhage in a cat secondary to suspected anticoagulant rodenticide intoxication.

A 6-month-old intact female mixed-breed kitten presented with severe exophthalmos of the left eye. Periocular lesions, including subconjunctival haemorrhage, third eyelid protrusion, and left eyelid oedema, were detected in the absence of globe retropulsion. The left intraocular pressure was increased, and ocular ultrasonography revealed ipsilateral retrobulbar fluid. Coagulation panels were markedly prolonged and severe anaemia was detected. Ultrasound-guided retrobulbar centesis performed to decrease intraocular pressure yielded blood. Based on the history and clinical findings, anticoagulant rodenticide intoxication was suspected. Treatment included partial tarsorrhaphy and the administration of topical antibiotics, artificial tears, and vitamin K1. Fresh whole blood and fresh frozen plasma were transfused for supportive therapy. Coagulation parameters improved after 7 days of hospitalisation. The periocular lesions resolved within 14 days, despite persistent optic nerve damage and blindness. This case report raises the possibility that anticoagulant rodenticide toxicity may result in retrobulbar haemorrhage in the absence of other typical cavitary bleeding. Although uncommon, anticoagulant rodenticide toxicity should be considered in cats with retrobulbar haemorrhage.

Traumatic Orbital Compression Syndromes: A Comprehensive Study Into Etiologies, Intervention Strategies, and Clinical Outcomes.

Facial fractures and their historical link to potential blindness have been well-documented, often attributed to optic canal injuries or retinal vascular occlusion. This dire consequence can result from both direct and indirect ocular trauma, including retrobulbar hemorrhage. Traumatic orbital compression can manifest in various forms, such as hematomas, fractured bone fragments, and emphysema, all posing a significant threat to vision, necessitating immediate intervention. In this study, 9 clinical cases of traumatic orbital compression are presented, each characterized by distinct etiologies. The study delves into traumatic orbital compressive syndromes, underscoring the critical imperative of early recognition and treatment to prevent vision loss. Orbital compression, whether from edema, hematoma, or emphysema, collectively culminates in elevated intraorbital pressure and the potential for optic nerve ischemia. Through the presentation of these 9 clinical cases, the article emphasizes the pressing need for timely intervention in addressing orbital compressive syndromes to avert vision loss. Various surgical techniques are elucidated, highlighting the pivotal role of expeditious medical intervention. This article offers invaluable insights into the diagnosis, management, and outcomes of traumatic orbital compressive syndromes.

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.

Occurrence of acute retrobulbar hemorrhage during birth.

OBJECTIVE: Presentation of acute retrobulbar subperiostal hemorrhage (hematoma) in the course of delivery. The occurrence, possible threats and recommended methods of treatment are described. Introduction: Acute retrobulbar hemorrhage is always a serious condition. Even if not connected with other ocular trauma, it could cause permanent blindness. The reason is based on constriction of the eye, decreasing of the blood supply and thus disruption of the oxygen supply to sensitive retinal tissues. After a short time, these tissues start to deteriorate and lose their natural function. This event is often connected with exophthalmia and diplopia. The primary diagnostic procedure is to measure intraocular pressure (IOP). Even if the ideal diagnostic tools are not accessible, performing a lateral canthotomy (event. with inferior cantholysis) is recommended to relieve IOP in acute situations. Normal intraocular pressure is considered to be 8-21 mmHg. Case report: Our 29-year-old female patient was in the second stage of delivery and suddenly got retrobulbar hemorrhage, resulting in exophthalmia and diplopia. Her baby was delivered shortly after the event. The following delivery course was normal, including her perineum repair and puerperium. Our patient was fortunate because her visual acuity and IOP were normal. Therefore, we chose an observational treatment strategy. After 5 weeks, we noted successful disintegration of the hematoma and decreased exophthalmia and diplopia without other consequences. Conclusion: We described retrobulbar subperiostal bleeding in our patient in the course of delivery. We depicted possible threats that could result in blindness and described recommended methods of treatment. Even if such a situation is extremely rarely, we believe that knowledge of these guidelines could help medical professionals broaden their treatment options. This particularly occurs when a trained eye surgeon is not available.

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.

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.

Retrobulbar hemorrhage decompression with paracanthal "one-snip" method: Time to retire lateral canthotomy?

Orbital compartment syndrome is a rare but serious condition most commonly as a result of traumatic retrobulbar hemorrhage and must be treated quickly to avoid ischemic damage to the optic nerve and retina. While the previously accepted standard of care for management of this condition has been lateral canthotomy with inferior cantholysis, this procedure can be challenging for physicians to perform given the rarity of the condition and that patients are frequently in significant pain often with significant periocular edema. In this case, orbital compartment syndrome was effectively treated with a paracanthal "one-snip" incision quickly and efficiently in the ED. This procedure offers a more manageable alternative treatment which has been found to produce a satisfactory intraocular pressure reduction in both cadaver models and now a patient with confirmed retrobulbar hemorrhage and resultant orbital compartment syndrome.

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?

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 postpartum lateral rectus haemorrhage.

A postpartum woman presented with sudden-onset left eyelid swelling and severe pain. Clinical examination revealed left exophthalmos and ophthalmoplegia with marked resistance to retropulsion of the left globe. The patient was not able to perceive light in the affected left eye and a relative afferent pupillary defect was present. CT orbits showed an enhancing lesion in the left retrobulbar space, suggestive of a lateral rectus haemorrhage. An emergency left lateral canthotomy and inferior cantholysis was performed. A day later, an MRI showed expansion of the left lateral rectus with significant mass effect on the globe. As the visual acuity remained reduced at counting fingers and there was a persistent relative afferent pupillary defect (RAPD), an exploratory orbitotomy and haematoma evacuation was performed. Three days postoperatively, the visual acuity had returned to 6/6. Eye movements normalised within 2 weeks and follow-up imaging revealed near complete resolution of the haematoma.

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.

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.