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Retro-orbital Hematoma, Emergency Medicine

Basics

Description

- 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

- Methylprednisolone - 30 mg/kg loading dose - 15 mg/kg q6h

  • 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 trauma0.45 " 0.6% coexist with orbital wall fractures0.0052% of blepharoplasty0.3% of surgical facial fracture repair0.006% 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

  • Methylprednisolone30 mg/kg loading dose15 mg/kg q6h
  • Mannitol1.5 " 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)