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.

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.

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 haemorrhage associated with anticoagulants].

Retrobulbar hemorrhage consists of bleeding in the retroseptal intraorbital region generating an orbital compartment syndrome. We present the case of an 86-year-old woman who came to the Emergency Room due to ocular pain and loss of vision in the left eye of six hours of evolution. The only medical history was atrial fibrillation on anticoagulant treatment with Dabigatran 300mg daily. The clinical examination was compatible with retrobulbar hemorrhage and the urgent CT confirmed the diagnosis, performing immediately after a canthotomy with cantolysis. In the absence of triggering factors, an orbital MRI was performed which ruled out the existence of arteriovenous malformations, diagnosing spontaneous retrobulbar hemorrhage associated with the use of anticoagulants. The uniqueness of this case is that it forms part of the small percentage of retrobulbar hemorrhages that are not associated with trauma or postsurgical causes, as well as in illustrating a very rare location of bleeding associated with anticoagulation.

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.

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.

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.

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.

[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.

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.

Visual outcomes after traumatic retrobulbar hemorrhage are not related to time or intraocular pressure.

BACKGROUND: The paucity of literature regarding the role of time and intraocular pressure (IOP) when treating ocular compartment syndrome (OCS) has resulted in limited guidance for emergency physicians (EP). OBJECTIVES: Our goals were to investigate the ideal time frame for lateral canthotomy, to understand the relationship between IOP and visual outcome, and to determine the impact of EP performance on visual acuity (VA). METHODS: The study population included patients presenting over an 18-year period with traumatic retrobulbar hemorrhage (RBH) treated with lateral canthotomy. Efficacy was evaluated using visual outcome and IOP. Patients were grouped by time from injury and arrival to canthotomy. Procedures completed in the emergency department (ED) and by EPs were evaluated regarding visual outcome. RESULTS: Sixty cases of RBH treated with lateral canthotomy were identified. Over two-thirds (43/60, 71.7%) were discharged with baseline vision. Lateral canthotomy lowered IOP from a median of 50.0 mmHg (IQR: 40.5, 61) preprocedure to 23.0 mmHg (IQR: 18, 27) post-procedure (p-value = 0.000001). No correlation was found between time, IOP, location, specialty of clinician, and visual outcome. CONCLUSION: Lateral canthotomy is an effective at lowering IOP. Our data suggest that using time and IOP to predict procedural outcome is flawed. If OCS is suspected, lateral canthotomy should be considered and can be effectively performed by EPs. Neither the time of injury to ED presentation nor degree of IOP elevation should be factored into the decision of when to perform the procedure.

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.