Basics
Description
- Also known as retrobulbar hematoma
- Rare complication of orbital trauma and facial surgery
- Collection of blood behind the globe causing increased retro-orbital pressure leading to tissue ischemia
- Vision loss can occur within 90 min if not diagnosed and treated with irreversible damage at 120 min
- A sight-saving procedure called lateral canthotomy is often needed to be performed in the emergency department
- A thorough exam is needed as many patients with ROH may be unconscious
- Frequent repeat exams are mandatory due to hematoma progression
Epidemiology
- Incidence is difficult to estimate because ROH can be from multiple causes, both traumatic and iatrogenic.
- 0.45 " 3% of blunt or penetrating trauma
- 0.45 " 0.6% coexist with orbital wall fractures
- 0.0052% of blepharoplasty
- 0.3% of surgical facial fracture repair
- 0.006% of endoscopic sinus surgery
- True incidence has been debated as only slightly more than half of diagnosed retro-orbital hemorrhage has been confirmed either with a preceding CT scan or with the presence of an evacuated hematoma.
Etiology
- Trauma to the globe or orbital walls and the orbital plexus
- Rapid increasing pressure behind the orbit secondary to hematoma formation impedes venous outflow and arterial inflow to the retina and the optic nerve to cause orbital compartment syndrome
- There may also be a stretching to the optic nerve as the patient develops proptosis which contributes to the decrease in visual acuity
Diagnosis
Signs and Symptoms
History
- Penetrating or blunt trauma to the orbit
- Recent facial/orbital surgery
- Eye pain
- Vision loss
Physical Exam
- Decreased visual acuity
- Increased IOP
- Proptosis
- Diplopia
- Pain
- Decreased EOM
- Relative afferent papillary defect, preserved consensual reflex
Essential Workup
- Obtain history of injury
- High degree of suspicion
- Thorough physical exam
- Evaluate for immediate surgical decompression
- STAT ophthalmology consult
- Imaging
Diagnosis Tests & Interpretation
Lab
None diagnostic or suggestive of this diagnosis
Imaging
- CT scan is gold standard but do not delay sight-saving intervention pending imaging
- Ultrasound (bedside if available): Sensitivity/specificity not studied. "Guitar-pick " sign.
Differential Diagnosis
The patient may present after trauma to the face with any of the following:
- Decreased vision
- Blurry vision
- Eye pain
- Eye discharge
- Photophobia
- Eye pressure
- Nausea and vomiting
The patient may present after having the following procedures:
- Reduction of facial fracture
- Eyelid surgery
- Endoscopic sinus surgery
- Regional anesthesia via retrobulbar injection
- Dacryocystectomy
One must consider as their differential:
- Orbital fracture
- Retro-orbital edema
- Retro-orbital emphysema
- Blow-in fractures
- Orbital roof fractures with brain herniation
- Intracranial bleeds
- Other major trauma associated with injury
Treatment
Pre-Hospital
- ABCs
- Pre-hospital lateral canthotomy very controversial
Initial Stabilization/Therapy
- ABCs
- Immediate transfer to Level 1 Trauma Center
- If past window of 90 " 120 min, lateral canthotomy & inferior cantholysis may be attempted by competent physician provider
Ed Treatment/Procedures
Surgical therapy:
- Indication: IOP >40, proptosis in unconscious patient
- Contraindication: Ruptured globe.
- The only definitive treatment
Lateral canthotomy and inferior cantholysis:
- Prep site with 5% Betadine
- Local anesthesia of cutaneous and deep tissues lateral to angle of the eye. Take caution to avoid the globe and orbit
- Clamp across the lateral canthus with hemostats for ¢ ¼1 min
- With blunt scissors cut in lateral fashion along clamp marks from lateral angle of eyelid to the orbital rim
- Expose the inferior and superior crus of the lateral canthal tendon by pulling down the lateral aspect of the lower lid
- Ligate the inferior crus at its insertion into the lower lid with blunt scissors. The lower lid should relax downward
Medication
- Methylprednisolone
- 30 mg/kg loading dose
- 15 mg/kg q6h
- Mannitol
- 1.5 " 2 g/kg over 30 min, with the 1st 12.5 g over 3 min
- Acetazolamide: 500 mg intravenously (do not use if allergic to sulfa or sickle cell pts)
- Hyperbaric oxygen
Follow-Up
Disposition
Admission Criteria
- All patients with suspected ROH should be admitted for definitive treatment in the OR and observation
- All patients need to be followed by an ophthalmologist
- All patients need to be worked up for other significant trauma
Discharge Criteria
Patients should not be discharged
Issues for Referral
- STAT ophthalmology consultation in the ED
- Do not delay decompression procedure due to consultation delay
- Emergency lateral canthotomy is within the scope of practice for emergency physicians
Pearls and Pitfalls
- Delayed diagnosis of retro-orbital hematoma due to:
- Lack of suspicion
- Lack of equipment such as a Tono-Pen:
- Waiting for CT/imaging thereby delays sight saving procedure
- Delayed consultation arrival
Additional Reading
- Allen M, Perry M, Burns F. When is retrobulbar haemorrhage not a retrobulbar haemorrhage? Int J Oral Maxillofac Surg. 2010;39:1045 " 1049.
- Ballard SR, Enzenauer RW, O 'Donnell T, et al. Emergency lateral canthotomy and cantholysis: A simple procedure to preserve vision from sight threatening orbital hemorrhage. J Spec Oper Med. 2009;9(3):26 " 32.
- Chen YA, Singhal D, Chen YR, et al. Management of acute traumatic retrobulbar haematomas: A 10-year retrospective review. J Plast Reconstr Aesthet Surg. 2012;65(10):1325 " 1330.
- Colletti G, Valassina D, Rabbiosi D, et al. Traumatic and iatrogenic retrobulbar hemorrhage: An 8-patient series. J Oral Maxillofac Surg. 2012;70(8):e464 " 468.
- Lewis CD, Perry JD. Retrobulbar hemorrhage. Expert Rev Ophthalmol. 2007;2(4):557 " 570.
Codes
ICD9
376.89 Other orbital disorders
ICD10
- H05.239 Hemorrhage of unspecified orbit
- S05.10XA Contusion of eyeball and orbital tissues, unsp eye, init
- S05.11XA Contusion of eyeball and orbital tissues, right eye, init
- S05.12XA Contusion of eyeball and orbital tissues, left eye, init
- H05.231 Hemorrhage of right orbit
- H05.232 Hemorrhage of left orbit
- H05.233 Hemorrhage of bilateral orbit
- H05.23 Hemorrhage of orbit
SNOMED
- 194179009 retrobulbar hemorrhage (disorder)