Treatment of Intraorbital Hemorrhage
Immediate assessment of visual acuity, pupillary examination, intraocular pressure, and exophthalmometry is critical, followed by urgent medical management with high-dose steroids and mannitol/acetazolamide for vision-threatening cases, with surgical orbital decompression reserved for patients who fail medical therapy or present with rapidly progressive vision loss. 1
Initial Emergency Assessment
The first priority is rapid evaluation to determine if orbital compartment syndrome threatens vision:
- Measure visual acuity immediately to establish baseline and identify vision-threatening hemorrhage 1
- Assess pupillary function for afferent pupillary defect indicating optic nerve compromise 1
- Measure intraocular pressure as elevated IOP suggests compartment syndrome 1
- Perform exophthalmometry to quantify proptosis severity 1
- Evaluate ocular motility for restriction suggesting muscle compression or entrapment 1
- Check for oculocardiac reflex (bradycardia, heart block, nausea, vomiting) which indicates urgent surgical intervention 2, 1
Immediate Hemorrhage Control
- Apply direct pressure to obvious bleeding points using pressure, tourniquet, or hemostatic dressings as first-line management 1
- Actively warm the patient if significant hemorrhage is present to prevent coagulopathy 1
Imaging Protocol
Non-contrast thin-section orbital CT with multiplanar reconstructions is the imaging modality of choice 1, 3:
- CT is superior for identifying orbital fractures, displaced fragments, and hemorrhage location 1
- MRI is contraindicated if metallic foreign bodies are suspected due to risk of object movement 1, 3
- Contrast is typically unnecessary in the acute trauma/hemorrhage setting 3
Medical Management Algorithm
For vision-threatening orbital compartment syndrome:
- High-dose corticosteroids to reduce inflammation and swelling 1
- Mannitol and/or acetazolamide to decrease intraorbital pressure 1
- Assess anticoagulation status as patients on anticoagulants have higher risk for postoperative hemorrhage 1, 4
The evidence shows medical management alone may be insufficient in severe cases. One case series demonstrated that systemic corticosteroids failed to improve clinical status in spontaneous intraorbital hemorrhage requiring surgical intervention 5.
Surgical Intervention Indications
Immediate surgical orbital decompression is indicated when:
- Vision-threatening symptoms progress despite medical management 5, 6, 7
- Rapid progression to blindness occurs (requires aggressive intervention within hours) 6
- Oculocardiac reflex is present and non-resolving 2, 1
- Severe proptosis with afferent pupillary defect develops 7
Surgical approaches include:
- Extended pterional orbital decompression for diffuse hemorrhage 7
- External ethmoidectomy or transantral approach for specific anatomic locations 6
- Lateral canthotomy with cantolysis for immediate pressure relief 4
A retrospective series of 16 patients showed complete proptosis reduction in all cases and visual acuity improvement in 75% when decompression occurred within mean 30.5 hours of symptom onset 7.
Special Considerations
Traumatic vs. Spontaneous Hemorrhage
- Assess for associated injuries in traumatic cases including globe rupture, optic nerve injury, and orbital fractures 1
- Consider vascular malformations in spontaneous cases, particularly arteriovenous malformations which can cause massive hemorrhage 5, 8
- Evaluate for anticoagulation as spontaneous retrobulbar hemorrhage is rare but documented with dabigatran and other anticoagulants 4
Timing Pitfalls
Missing the narrow window for intervention is the most critical error - blindness from intraorbital hemorrhage requires immediate aggressive intervention with potential to restore vision only if treated within hours 6. Delayed recognition of orbital compartment syndrome leads to irreversible optic nerve damage 7.
Follow-Up Monitoring
After hemorrhage control: