What is the treatment for orbital hemorrhage?

Treatment of Orbital Hemorrhage

Immediate lateral canthotomy and cantholysis followed by surgical decompression is the standard treatment for orbital hemorrhage causing vision-threatening orbital compartment syndrome. 1, 2

Initial Assessment and Management

• Orbital hemorrhage should be recognized as a potential emergency that can lead to permanent vision loss if not treated promptly 3
• Immediate assessment should include evaluation of:
  • Visual acuity
  • Pupillary examination
  • Intraocular pressure measurement
  • Exophthalmometry (to measure proptosis)
  • Ocular motility 4
• Control of obvious bleeding points using pressure, tourniquet, or hemostatic dressings should be the first step 4

Emergency Treatment Algorithm

For Vision-Threatening Orbital Compartment Syndrome:

1. Immediate Intervention (within minutes to hours):

   • Lateral canthotomy and cantholysis as an emergency measure to relieve pressure 2, 5
   • This procedure can be performed at bedside under local anesthesia 1

2. Medical Management (concurrent with surgical planning):

   • High-dose steroids to reduce inflammation and swelling 6
   • Mannitol and/or acetazolamide to reduce intraocular pressure 6
   • Actively warm the patient if there is significant hemorrhage 4

3. Definitive Surgical Management:

   • Surgical evacuation of the hematoma through appropriate approach 5
   • Pterional orbital decompression for cases requiring maximal decompression 5
   • Identification and control of bleeding source when possible 2

For Non-Vision-Threatening Orbital Hemorrhage:

• Conservative management with close observation may be appropriate 6
• Serial examinations of visual acuity, pupillary response, and intraocular pressure 4
• Short burst of oral steroids can hasten recovery of orbital edema/hematoma 4

Imaging Considerations

• Non-contrast thin-section orbital CT with multiplanar reconstructions is the imaging modality of choice 4
• CT is superior for identifying orbital fractures and displaced fragments 4
• MRI is contraindicated if there is suspicion of metallic foreign bodies in the orbit 4

Special Considerations

• Patients on anticoagulation may be at higher risk for postoperative orbital hemorrhage 4
• In cases of orbital trauma with hemorrhage, assessment for other injuries is essential 4
• The oculocardiac reflex (presenting with bradycardia, heart block, dizziness, nausea, vomiting) may indicate muscle entrapment requiring urgent intervention 4, 7

Follow-up Care

• After control of orbital hemorrhage, monitor for:
  • Persistent diplopia (may require strabismus surgery if it persists beyond 4-6 months) 4
  • Enophthalmos or hypoglobus (may require orbital reconstruction) 4
  • Development of restrictive strabismus 4
  • Standard venous thromboprophylaxis should be commenced as soon as bleeding is controlled 4

Common Pitfalls to Avoid

• Delaying treatment in cases of vision-threatening orbital compartment syndrome 5
• Failing to recognize the signs of oculocardiac reflex, which can be life-threatening 7
• Inadequate decompression leading to persistent pressure on the optic nerve 5
• Missing associated injuries in cases of traumatic orbital hemorrhage 4

While some cases of orbital hemorrhage may resolve spontaneously 6, the potential for permanent vision loss makes prompt recognition and treatment essential in cases with signs of orbital compartment syndrome 3, 5.