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.

Incidence and management of retrobulbar hemorrhage after blowout fracture repair.

BACKGROUND: Retrobulbar hemorrhage (RBH) is a rare complication after orbital surgery but associated with ocular complications including blindness. The aim of this study was to identify clinical characteristics of patients with RBH requiring emergent orbital decompression after blowout fracture repair. METHOD: A retrospective review of 426 blowout fracture patients at a tertiary oculoplastic clinic provided data regarding demographics, physical examination findings, and computed tomography (CT) images. Extraocular motility had been recorded in patient charts on a scale from 0 to - 4. Patients requiring emergent orbital decompression due to RBH after surgery (RBH group) were compared with those who did not (Control group), using the Mann-Whitney U-test. Incidences of RBH according to primary or secondary surgery were also investigated, using Fisher's exact test. RESULT: Five (1.2%) of the 426 patients who underwent blowout fracture repair developed RBH requiring emergent intervention. All RBH patients fully recovered after the decompression procedure or conservative treatment. Number of days to surgery was significantly longer in the RBH group (97.0 ± 80.1) than in the Control group (29.0 ± 253.0) (p = 0.05). Preoperative enophthalmos was also significantly greater in the RBH group (RBH vs. Control group, 3.6 ± 1.7 mm versus 1.2 ± 1.3 mm (p = 0.003)). The incidence of RBH was significantly higher in patients that underwent secondary surgery (odds ratio = 92.9 [95% confidence interval, 11.16-773.23], p = 0.001). CONCLUSIONS: Surgeons should pay more attention to hemostasis and postoperative care in patients with a large preoperative enophthalmic eye, when time from injury to surgery is long and in revision cases. When RBH occurs, time to intervention and surgical decompression is critical for visual recovery and preventing blindness. TRIAL REGISTRATION: The institutional review board of the Yeungnam University Medical Center approved this study ( YUMC 2018-11-010 ), which was conducted in accord with the Declaration of Helsinki.

Incidence and outcomes of retrobulbar hematoma diagnosed by computed tomography in cases of orbital fracture.

OBJECTIVE: Retrobulbar hemorrhage (RBH) is a potentially sight-threatening complication of orbital fractures causing an orbital compartment syndrome (OCS). RBH causing OCS is regarded as a clinical diagnosis when evidence of optic nerve compression is found. Nonetheless, many patients with facial trauma will have received imaging by computed tomography (CT) on which there is documented RBH, with or without signs of OCS. The aim of this study was to identify the incidence and describe the outcomes of these CT-diagnosed RBH. METHODS: This is a retrospective chart review of patients with orbital fractures for which ophthalmology was consulted. Confirmation of orbital fracture and presence of an RBH on facial-bones CT was recorded. Patient demographics, proptosis, visual acuity, intraocular pressure and interventions received at initial visit and follow-up were recorded. RESULTS: 292 orbits with wall fractures were identified. 94 (32.2%) were documented by CT to have RBH. Of these orbits, only one (1.1%) was diagnosed with OCS receiving canthotomy and cantholysis. 53 orbits with initial CT-diagnosed retrobulbar hematoma were seen in follow-up a week or more later, none of which had developed signs of OCS or needed medical or surgical intervention for OCS. CONCLUSIONS: RBH is a frequently reported finding on CT in cases of orbital fractures. In this study, almost all of these CT-diagnosed RBH did not develop OCS initially or by the time of follow-up. CT presence of RBH is not an accurate predictor for OCS, and the diagnosis and treatment of OCS should be directed clinically.

Retrobulbar hematoma: A systematic review of factors related to outcomes.

INTRODUCTION: Retrobulbar hematoma (RBH), a rare but serious condition, can result in permanent vision loss. Although it is a known complication following trauma or facial fracture reduction, sinus surgery, or blepharoplasty, factors related to patient outcomes are not well-defined. A systematic review was performed to determine the relation of patient/treatment factors to outcomes. METHODS: Articles retrieved from a PubMed search (1989-2017) were reviewed. Demographic information, etiology, symptoms, and final vision outcomes were analyzed using Fisher's exact tests, single and multiple predictor logistic regression. RESULTS: Of 429 articles identified, 16 were included in the study. 93 cases of retrobulbar hematoma were included. 74% occurred after trauma, while 26% occurred postoperatively. Onset of symptoms occurred after approximately 24 hours. 28% received treatment within 1 hour, 54% within 1-24 hours, and 18% after 24 hours. 51% had complete visual recovery, while 27% had partial recovery, and 22% developed blindness. Older patients and patients who sustained trauma were less likely to have a full recovery (p = 0.029, p = 0.023). Increasing number of symptoms trended towards a prediction of blindness (p = 0.092). Surgical decompression and shorter time to treatment were each highly predictive of full recovery (p = 0.024, p = 0.003) and decreased likelihood of blindness (p = 0.037, p = 0.045); use of steroids was not found to be significant. DISCUSSION: Retrobulbar hematoma is a diagnostic and therapeutic emergency. Factors associated with improved outcomes include younger age, decreased number of total symptoms, surgical decompression, and shorter time to treatment. If recognized and treated early with surgical decompression, recovery of vision is possible.

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.

Intraoperative Complications of Cataract Surgery in Tehran Province, Iran.

PURPOSE: To determine the prevalence and types of intraoperative complications of cataract surgery and examine potential risk factors. METHODS: Data were obtained from the 2011 Iranian Cataract Surgery Survey in which information about cataract surgeries throughout the nation was collected. In the Province of Tehran, 55 centers and 1 week per season per center were randomly selected for sampling. In each center, the charts of all patients who underwent cataract surgery during the selected weeks (total of 20 weeks per center) were reviewed for data extraction. The prevalence of different types of intraoperative cataract surgery complications were determined, and their relationships with age, sex, surgical method, surgeon, and hospitalization time were examined. RESULTS: The prevalence of intraoperative complications of cataract surgery was 4.15% (95% confidence interval, 0.94 to 7.36). The prevalence of posterior capsular rupture with vitreous loss, posterior capsular rupture without vitreous loss, retrobulbar hemorrhage, suprachoroidal effusion/hemorrhage, intraocular lens drop, and nucleus drop was 2.86, 0.69, 0.06, 0.39, 0.03, and 0.11%, respectively. The prevalence of cataract surgery complications decreased from 6.95% in 2006 to 3.07% in 2010. The results of multiple logistic regression showed that surgery by residents, nonphacoemulsification methods of surgery, and patient age less than 10 years and more than 70 years were the risk factors for complications. CONCLUSIONS: This study evaluated the prevalence of intraoperative complications of cataract surgery for the first time in Tehran Province. The prevalence of complications was high in this study. To achieve the goals of the Vision 2020 Initiative and improve surgical quality, it is necessary to minimize complication rates. Factors to note for decreasing complication rates include type of surgery, surgeon experience, and patient age.

The estimation of postoperative bleeding after reduction of blowout fracture: the effectiveness of negative-pressure drainage system.

BACKGROUND: Retrobulbar hemorrhage is a rare complication of midface injury, blepharoplasty, facial fracture surgery, periorbital surgery, and circumbulbar anesthesia. The incidence of postoperative retrobulbar hemorrhage is 0.3% to 4% after the reduction of facial bone fracture. The purpose of this study was to estimate the postoperative bleeding after the reduction of a blowout fracture and to demonstrate the effectiveness of a negative-pressure drainage system with a scalp vein set tube. METHODS: From January 2006 to July 2013, we handled a total of 1491 cases of blowout fractures. Two of them (0.13%) were diagnosed as retrobulbar hematoma in 2011. After experiencing 2 cases of retrobulbar hematoma, we have been routinely using a scalp vein set tube as a negative-pressure drainage system to check the postoperative blood volume. RESULTS: From January 2012 to July 2013, a total of 131 patients underwent blowout fracture repair and experienced application of a negative-pressure drainage system. Their mean total drained amount was 12.6 mL; maximum amount was 47.5 mL in the 2 days after the surgery. The maximum drained amount was 41.7 mL on the day of the surgery. All the patients had no cardinal signs or symptoms of retrobulbar hematoma and no complications. CONCLUSIONS: Retrobulbar hematoma is a rare but critical surgical complication that leads to permanent visual loss. Considering the limited orbital cavity and postoperative edema, the volume of postoperative bleeding is thought to be enough to compress the optic nerve if the blood is not drained. Thus, we recommended a simple negative-pressure drainage system to prevent retrobulbar hematoma.

Incidence of retrobulbar hemorrhage in the emergency department.

Retrobulbar hemorrhage is a rare but potentially devastating complication of midface trauma. Management of this entity requires prompt diagnosis and medical and surgical interventions. The incidence of retrobulbar hemorrhage has been cited to be lower than 1%; however, despite a low rate of occurrence, lack of immediate care can lead to major morbidity for the patient. This report presents a retrospective evaluation of the incidence and management of post-traumatic retrobulbar bleed in the emergency department by an oral and maxillofacial surgery service at a tertiary care trauma center.

Traumatology of the facial skeleton in octogenarian patients: a retrospective analysis of 96 cases.

AIM: The aim of this retrospective study was to evaluate the frequency and distribution of maxillofacial trauma patients over 80 years, with regard to type and environment of accidents as well as treatment and complications. PATIENTS AND METHODS: Data for 94 patients (96 cases; aged 80-94 years) with maxillofacial fractures were retrospectively analysed. RESULTS: Data of 30 male and 64 female patients with an average age of 85 years were analysed. In 90% of the study population, the cause of fractures was a fall, followed by traffic accidents (9%) and assault (1%). Seventy-two patients had fractures of the midface, 10 had factures of the mandible, 9 had fractures of both the midface and mandible and 5 had fractures of the neurocranium and midface. Surgical intervention was required in 57% of the patients. Post-operative complications were: four cases of diplopia, two cases of infected plates, four cases of lower eyelid ectropion and in one case a retrobulbar haematoma. CONCLUSION: Facial trauma in the elderly can often be treated conservatively unless the patient complains of functional problems. Due to co-morbidities, special attention should be paid to hypertension, anticoagulant agents and the surgical approach.

Anestesia subtenoniana en cirugía del globo ocular: revisión / Sub-Tenon block for ocular globe anesthesia: a review

La anestesia subtenoniana es una técnica efectiva y bien tolerada que permite realizar intervenciones de la cámara anterior y posterior del ojo. Ofrece similares ventajas que la anestesia peribulbar y retrobulbar al tiempo que minimiza sus complicaciones. La anestesia subtenoniana proporciona mejor analgesia que aquinesia. Frente a las anestesias tópica e intracamerular, la mayoría de estudios aboga por la anestesia subtenoniana como la técnica de elección, ya que disminuye los potenciales efectos adversos de las otras técnicas regionales y proporciona mejor analgesia y aquinesia(AU)

Sub-Tenon anesthesia is an effective, well-tolerated technique for surgery in the anterior or posterior compartments of the eye. The advantages of this block are comparable to those of peribulbar and retrobulbar anesthesia and complications are minimal. Sub-Tenon anesthesia provides better analgesia than akinesia. Most studies suggest that sub-Tenon anesthesia is a good technique to choose, given that potential adverse effects are fewer than for other regional blocks and analgesia and akinesia are superior(AU)

Management of orbital complications in endoscopic sinus surgery.

PURPOSE OF REVIEW: Minor and major complications can occur during endoscopic sinus surgery. Even though major complications are rare, orbital complication is one of the more common major complications that can lead to devastating consequences. This article summarizes the orbital complications that can occur during endoscopic sinus surgery, how to manage the complication when it occurs, and more importantly how to avoid these complications. RECENT FINDINGS: One of the orbital complications during endoscopic sinus surgery is retrobulbar hematoma. Retrobulbar hematoma can be classified as spontaneous, traumatic, and iatrogenic. Iatrogenic hematoma, which can be caused by endoscopic sinus surgery, is more likely to have an arterial source, so these hematomas have higher tonometric pressure and may require more aggressive management. However, medical management can be an option for some of these iatrogenic retrobulbar hematomas. Tonometric pressure may be the best indicator to decide which intervention to use for this complication. Another distressing orbital complication is injury to the oculomotor muscles. With prompt medical and surgical intervention, the ocular dysmotility can be compensated. SUMMARY: Consequences of orbital injury during endoscopic sinus surgery can be devastating; however, with proper medical or surgical treatment potential morbidities can be minimized.

Anestesia tópica más subconjuntival versus retrobulbar en la esclerectomía profunda no penetrante / Combined topical plus subconjunctival anesthesia versus retrobulbar anesthesia in non-penetrating sclerectomy

Objetivo: Comparar la eficacia y seguridad de la anestesia tópica-subconjuntival con la retrobulbar en la escleroctomía profunda no penetrante suplementada con 5-FU. Método: Se realizó un estudio prospectivo y aleatorizado de 30 pacientes consecutivos a los que se les practicó anestesia tópica-subconjuntival (n=14) o retrobulbar (n=16). Se evaluaron las condiciones operatorias, el confort del paciente, el dolor postoperatorio, el dolor total y el resultado quirúrgico en cuanto a bajada de presión intraocular. Resultados: No hubo diferencias en las condiciones quirúrgicas entre ambos grupos. El grupo con anestesia retrobulbar refirió más dolor durante la aplicación del anestésico (P= 0,00). El grupo con anestesia tópica-subconjuntival refirió más disconfort intraoperatoriamente (P=0,00). Sin embargo, esto no representó un problema para el cirujano. No hubo diferencias en el dolor postoperatorio entre ambos grupos. No hubo diferencias estadísticamente significativas en cuanto al dolor total. No hubo diferencia en cuanto al éxito quirúrgico entre ambos grupos. Conclusiones: La anestesia tópica-subconjuntival es una alternativa segura y efectiva para la escleroctomía no penetrante suplementada con 5-FU

Purpose: To compare the safety and efficacy of topical plus subconjunctival versus retrobulbar anesthesia for primary non-penetrating sclerectomy supplemented with adjuntive 5-FU. Methods: A prospective study of 30 consecutive patients who were randomized to receive subconjunctival (n = 14) or retrobulbar (n = 16) anesthesia was performed. Operating conditions, patient comfort, postoperative pain, total pain and surgical outcomes were evaluated. Results: There were no differences in the operating conditions. The retrobulbar group reported significantly more pain during administration of the anesthetic agent than the subconjunctival group (P= 0.00). The subconjunctival group reported more discomfort during surgery than the retrobulbar group (P= 0.00); however, this feature was not a problem for the surgeon. No statistically significant differences were found in regard to the total pain experienced, the postoperative pain, nor the success rates of the operative procedure in either group. Conclusion: Topical/subconjunctival anesthesia is a safe and effective alternative to retrobulbar anesthesia for non penetrating sclerectomy supplemented with 5-FU

Incidence of postblepharoplasty orbital hemorrhage and associated visual loss.

PURPOSE: Orbital hemorrhage, especially when associated with visual loss, is a significant complication of cosmetic eyelid surgery. We investigated the incidence of this complication among cases handled by members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. We also reviewed the length of time between surgery and the onset of bleeding and sought any factors that may contribute to these cases. METHODS: A 2-page questionnaire was sent to all American Society of Ophthalmic Plastic and Reconstructive Surgery members. Responses were tabulated as to total numbers of cases performed, the incidence of postoperative orbital hemorrhage, treatments, and incidence of permanent visual loss. Comorbidities were also reviewed. RESULTS: Two hundred thirty-seven responses were received from American Society of Ophthalmic Plastic and Reconstructive Surgery members, collectively representing 269,433 cases. Among these cases, there were 149 orbital hemorrhages, 48 cases associated with temporary visual loss, and 12 cases associated with permanent visual loss. The majority of these cases occurred within the first 3 hours of surgery, and the risk decreased significantly after 24 hours after surgery. Common comorbidities were hypertension, perioperative aspirin use, postoperative vomiting, and increased physical activity. Treatment commonly consisted of wound drainage with cauterization of active bleeders, lateral canthotomy, intravenous steroids, and intraocular pressure-lowering drugs. Orbital decompression was infrequently used; anterior chamber paracentesis was not used. This study is limited by recall biases regarding the number of cases performed by each responding surgeon and the number of relevant cases of orbital hemorrhage. CONCLUSIONS: The incidence of orbital hemorrhage associated with cosmetic eyelid surgery is 0.055% (1:2,000), and orbital hemorrhage with permanent visual loss is 0.0045% (1:22,000) [corrected] Development of orbital hemorrhage is most common within the first 24 hours after surgery, especially within the first 0 to 3 hours, but can occur as late as several days after surgery.

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.

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.