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.

A case report of orbital haemorrhage associated with endoscopic sinus surgery and reversible sight loss: a multidisciplinary approach to management.

We report a case of intraoperative orbital haemorrhage as a complication of endoscopic sinus surgery performed under general anaesthesia. Initial unilateral complete visual loss occurred, but recovered due to accurate and early diagnosis combined with urgent surgical intervention. This patient's case is reported to illustrate the importance of early recognition of clinical signs and how a stepwise approach to management can result in a favourable visual outcome. Moreover, the mechanisms and pathophysiology of visual loss due to orbital haemorrhage following endoscopic sinus surgery are discussed.

Mechanisms and management of vision loss following orbital and facial trauma.

PURPOSE OF REVIEW: To examine the proposed mechanisms of vision-threatening injuries occurring secondary to orbital and facial trauma: traumatic optic neuropathy (TON), retrobulbar haemorrhage (RBH) and penetrating eye injury. To evaluate the evidence supporting different management options for traumatic vision-threatening injury. RECENT FINDINGS: Despite considerable debate over the roles of surgical decompression and systemic steroid therapy for TON, these interventions have not been proved to be more effective than conservative management and there is limited evidence that the use of steroids may be associated with an adverse outcome. Lateral canthotomy and inferior cantholysis have been proven to be effective treatments for RBH. Orbital exploration and surgical evacuation of haematoma remains a second line intervention. Open globe injuries require immediate primary surgical exploration and repair. Irretrievable devastating globe injuries require either enucleation or evisceration. There is no consensus as to which is the best treatment with recent surveys indicating that enucleation is preferred in the USA and evisceration in the United Kingdom. SUMMARY: Conservative management is the first line treatment for TON. The evidence strongly supports lateral canthotomy and inferior cantholysis as best treatment for RBH. There is no consensus as to whether enucleation or evisceration is the best treatment for irretrievable devastating globe injury. The choice of management is currently determined by surgeon preference.

Orbital venous anomaly presenting with orbital hemorrhage.

PURPOSE: To report on the characteristics of patients with orbital venous anomaly presenting with acute orbital hemorrhage. METHODS: We retrospectively reviewed the clinical and radiologic findings of a case series of eight orbital venous anomaly patients who presented with orbital hemorrhage. Charts of patients diagnosed as having orbital venous anomaly who initially presented with orbital hemorrhage were selected. RESULTS: The eight patients with orbital venous anomaly (one man and seven women) ranged in age from 7 to 66 years (median, 22 years). The average duration of symptoms was 7 days (range, 1-30 days). All eight patients were totally asymptomatic prior to their acute presentations. Orbital computed tomography (CT) scans showed a well-demarcated ovoid mass in all eight patients. Five patients were referred with a suspicion of orbital tumor, and one underwent a lateral orbitotomy for a biopsy. In six patients, the presence of an orbital hemorrhage was identified by typical findings on orbital magnetic resonance imaging (MRI). After resolution of the hemorrhage, all patients evidenced a distensible orbital venous anomaly in an imaging study. CONCLUSION: An orbital venous anomaly presenting with sudden orbital hemorrhage can be mistaken for other orbital tumors. In patients with acute orbital process, orbital MRI for detecting hemorrhage and a follow-up CT scan after resolution of the hemorrhage are needed to prevent unnecessary surgical intervention.

Management of retrobulbar hematoma.

BACKGROUND: Retrobulbar hematoma (RH) is a complication that can result from both otolaryngic and ophthalmologic procedures. RH can occur during endoscopic sinus surgery and improper treatment can result in several morbidities, including visual loss. Despite serious consequences, management for RH is not well evaluated. However, lateral canthotomy with cantholysis is generally recommended. The objective of this study is to review the management for RH. METHODS: A retrospective study was performed at our tertiary hospital from 1979 to 2006 for patients with the ICD-9 code for orbital hematoma. The demographic information, comorbidities, presentation, management, follow-up period, and outcomes were evaluated. Data were analyzed. RESULTS: Twenty-two patients were identified with 13 male patients and an average age of 43 years (range, 11-80 years). The RH was broken into three categories: iatrogenic, six cases; trauma, eight cases; and spontaneous, eight cases. The most common symptom was diplopia followed by orbital pain. The average pretreatment and posttreatment tonometric pressures were 25.3 mm Hg (range, 11-60 mm Hg) and 14.5 mm Hg (range, 10-22 mm Hg), respectively. The average proptosis was 4.3 (range: 0-8) mm. Treatments were observation (13 cases), medical treatment alone (4 cases), and surgical treatment with and without medical treatment (5 cases). Sixty-eight percent of the patient's visual acuity improved with these treatments. Twenty-seven percent had no visual changes from the RH. The average follow-up was 5 years. CONCLUSION: Traditionally, lateral canthotomy with cantholysis is recommended for the treatment for RH. However, in certain patients and settings, there may be an acceptable alternative option for the management of RH.

Evaluation of intraocular and orbital pressure in the management of orbital hemorrhage: an experimental model.

OBJECTIVE: To evaluate orbital pressure (OP), intraocular pressure (IOP), and the effectiveness of canthotomy, cantholysis, and septolysis using an experimental orbital hemorrhage model. METHODS: Expired whole blood was injected into the retrobulbar space of 10 human cadaver orbits. At 1-mL increments, OP, IOP, and globe position were documented. The mean (SD) time interval between the injections was 84 (36) seconds. Following injection of 22 mL, lateral canthotomy, cantholysis, and septolysis were performed. An additional 10 mL of blood was then injected. RESULTS: After injecting 22 mL of whole blood, mean (SD) OP and IOP were 68.4 (32.2) and 71.5 (19.1) mm Hg, respectively. The OP and IOP correlated closely throughout the experiment, with a mean (SD) difference of 11.4 (4.9) mm Hg (Pearson coefficient, 0.97). Following canthotomy, cantholysis, and septolysis, there was a mean (SD) decrease of 48.0 (27.2) mm Hg (70%) and 50.0 (18.1) mm Hg (59%) in OP and IOP, respectively. With additional injection of 10 mL of blood, OP and IOP increased rapidly. CONCLUSIONS: The IOP and OP rose in direct proportion to the volume of whole blood injected; OP lagged behind IOP by 11 mm Hg, and surgical release of the orbit reduced OP by 70%. This effect was short-lived in the setting of continued simulated hemorrhage.

Management of acute orbital hemorrhage with obstruction of the ophthalmic artery during attempted coil embolization of a dural arteriovenous fistula of the cavernous sinus.

Because of inability to access a cavernous-carotid fistula through conventional means, a superior ophthalmic vein approach was used to allow access for embolization. Although there was initially robust flow through both the fistula and the ophthalmic artery on angiography, the flow stopped during the procedure, and the patient was found to have an orbital hemorrhage. Immediately on emergent canthotomy and evacuation of the hemorrhage, angiographic evidence of restoration of flow was noted. This finding suggests that vision loss in orbital compartment syndrome may be due to arterial occlusion in some cases, and may be reversible if prompt action is taken.

Visual recovery following emergent orbital decompression in traumatic retrobulbar haemorrhage.

INTRODUCTION: Acute retrobulbar haemorrhage is a potentially sight-threatening condition, and can follow retrobulbar anaesthesia or trauma to the orbit. Acute loss of vision can occur with retrobulbar haemorrhage and is reversible if the condition is recognised and treated early. CLINICAL PICTURE: We report a case of acute retrobulbar haemorrhage following orbital trauma in a 78-year-old Chinese lady. TREATMENT: The patient was on follow-up for a mature cataract in the right eye and had been scheduled for cataract surgery. The patient presented to the emergency department with acute loss of vision in the right eye, severe proptosis and tense periorbital haematoma after she hit her right face following a fall. Computed tomography scans revealed fractures of the floor, lateral and medial walls of the right orbit as well as retrobulbar and periorbital haematoma. There was marked proptosis and tenting of the globe with stretching of the optic nerve. Emergent lateral canthotomy and cantholysis was performed at the emergency department. The patient subsequently underwent surgical evacuation of the orbital haematoma. OUTCOME: The patient's vision in the right eye recovered from no perception of light to light perception over the next few days. After a month of follow-up, the patient underwent right cataract surgery, and her best corrected visual acuity was 6/12 part. CONCLUSION: In severe acute retrobulbar haemorrhage, prompt surgical evacuation of the haematoma can reverse visual loss.

Hemorrhagic ocular complications associated with the use of systemic thrombolytic agents.

OBJECTIVE: This study aimed to report three patients with hemorrhagic ocular and orbital complications associated with the use of systemic thrombolytic agents. DESIGN: The study design was a retrospective small case series. PARTICIPANTS: Three eyes of three patients were studied. INTERVENTION: Surgical procedures to reduce intraocular pressure or relieve optic nerve compression were performed. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure were measured. RESULTS: Three patients received an intravenous thrombolytic agent on diagnosis of an acute myocardial infarction. One patient had a spontaneous suprachoroidal hemorrhage develop with secondary acute angle closure glaucoma shortly after receiving tissue plasminogen activator. Another patient had an orbital hemorrhage develop on receiving tissue plasminogen activator 4 days after an uncomplicated cataract extraction. The third patient experienced an orbital hemorrhage while receiving streptokinase 1 day after undergoing an external levator resection. Two patients suffered significant visual loss due to glaucoma or compressive optic neuropathy. CONCLUSIONS: The onset of eye pain or visual loss after the administration of a systemic thrombolytic agent should alert the physician to the possibility of an ocular or adnexal hemorrhage. Prompt diagnosis and treatment can improve the likelihood of a favorable visual outcome.