Retrobulbar hematoma (RBH) is a vision-threatening emergency caused by the accumulation of blood in the retrobulbar space. Often associated with orbital trauma or a recent history of the eyelid or orbital surgery, RBH can lead to significantly elevated intraocular pressure (IOP) that can subsequently impede ocular perfusion and lead to vascular occlusion or optic nerve ischemia. Risk factors include Valsalva maneuvers such as coughing after orbital surgery, retrobulbar anesthesia, and anticoagulation use. Although RBH is rare, prompt recognition of its symptoms is imperative to facilitate timely and vision-salvaging treatment. The case of a young female with trauma-induced RBH is described here.
A 37-year-old female with a history of thyroid eye disease presented after suffering multiple fist punches to the right side of her face in a domestic violence assault. Upon presentation, she was conscious and oriented. Visual acuity in the right eye was light perception. The right pupil was nonreactive due to traumatic mydriasis, and a relative afferent pupillary defect (APD) was present. Extraocular motility was restricted in all directions of gaze. IOP in the right eye was 20 mmHg. There was gross proptosis of the right globe which was otherwise not ruptured; diffuse conjunctival chemosis and hemorrhage were observed [Figure 1a]. Computed tomography revealed an intraconal RBH with anterior herniation of the globe from the orbit [Figure 1b]. The extraocular muscles were thickened, consistent with her thyroid eye disease, but her superior rectus was also avulsed. The optic nerve was on stretch, but there was no evidence of transection. Although the IOP was normal, there was evidence of acute orbital compartment syndrome given the vision loss and APD, and the patient was treated emergently with lateral canthotomy and cantholysis along with cornea lubrication for exposure keratopathy. The patient ultimately underwent enucleation with the plan for an eventual ocular prosthesis.
The differential diagnosis of subconjunctival hemorrhage with proptosis almost always suggests a history of trauma. An open-globe injury must be ruled out. The suspicion for RBH must be high as an immediate intervention with a lateral canthotomy may be critical to preserve the vision. Other potential causes of unilateral proptosis include orbital cellulitis, inflammatory conditions (e.g., sarcoidosis), carotid-cavernous fistula, nonhemorrhagic orbital compartment syndrome, acute angle-closure glaucoma, and neoplastic tumors, although none of these are likely to be accompanied by subconjunctival hemorrhage. Thyroid eye disease is a common cause of bilateral proptosis, although it can present asymmetrically.
RBH is a rare, but rapidly progressive and vision-threatening emergency most often caused by blunt force trauma to the ocular or periocular region. It can also manifest as a complication of the eyelid or orbital surgery. In RBH, blood accumulates in the retrobulbar space and can lead to an increase in IOP, optic nerve stretch, or mechanical blockage of ocular perfusion. Risk factors include hypertension and vomiting or coughing after ocular surgery; the association between anticoagulation use and RBH remains unclear. Symptoms and signs of RBH include severe pain, loss of vision, unilateral proptosis, elevated IOP, periorbital ecchymosis, nausea, and vomiting.
First-line treatment for RBH is lateral canthotomy with cantholysis of the inferior canthal ligament. Early intervention is necessary to optimize visual outcomes. The incidence of blindness among patients with RBH can approximate 50%, but one study found that in patients who received proper and prompt treatment, the incidence decreased to 0.14%. Our particular patient also had a history of thyroid eye disease which may have contributed to the severe extent of her proptosis.
RBH is an ophthalmic emergency and is most commonly related to trauma, as it was in the case described here. Prompt diagnosis is critical for timely treatment which can optimize visual outcomes. For patients with elevated IOP, relative APD, proptosis, severe pain, visual decrease, ophthalmoplegia, or any other evidence of acute orbital compartment syndrome, a lateral canthotomy and cantholysis should be considered emergently.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.
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