From the Guidelines
Retrobulbar hematoma is an ophthalmologic emergency that requires immediate intervention with lateral canthotomy and cantholysis to prevent permanent vision loss, as supported by the most recent and highest quality study available 1.
Key Considerations
- The condition results from bleeding behind the eye, typically following trauma, surgery, or injection procedures, causing increased orbital pressure that compresses the optic nerve and retinal blood vessels.
- Without prompt treatment within 90-120 minutes, permanent vision loss occurs due to ischemic optic neuropathy.
- Treatment begins with discontinuation of anticoagulants and immediate lateral canthotomy and cantholysis to decompress the orbit.
- Medical management includes intravenous acetazolamide 500mg, mannitol 1-2g/kg IV over 30-45 minutes, and high-dose steroids such as methylprednisolone 250mg IV.
- Patients should be positioned with the head elevated to 30-45 degrees to promote venous drainage.
- Continuous monitoring of visual acuity, pupillary response, and intraocular pressure is essential.
Management Approach
- Ophthalmology consultation should be obtained immediately, but emergency physicians should not delay performing canthotomy if vision is threatened and specialist care is not immediately available.
- The risk of retrobulbar hematoma is increased in patients undergoing ophthalmologic procedures, including cataract surgery, while on anticoagulant therapy, as noted in a study on the management of anticoagulated patients undergoing elective procedures 1.
- However, the most recent and highest quality study available 1 provides guidance on the management of adult strabismus, including the potential complications of retrobulbar hematoma, and emphasizes the importance of prompt intervention to prevent permanent vision loss.
From the Research
Definition and Causes of Retrobulbar Hematoma
- Retrobulbar hematoma is a diagnostic and therapeutic emergency that may cause permanent vision loss 2
- It can be caused by trauma, eye surgery, vascular malformations, bleeding disorders, use of anticoagulants, and increased central venous pressure 3
- Spontaneous retrobulbar hematoma after heart transplantation is a rare condition that risks vision 3
Symptoms and Diagnosis
- The most common presenting ocular symptoms and signs are orbital pain and subconjunctival hemorrhage 2
- Clinical presentation of spontaneous retrobulbar hematoma consists of ocular pain, decreased visual acuity, conjunctival chemosis, proptosis, abnormal extraocular movements, and elevated intraocular pressure (IOP) 3
- Diagnosis is often clinical, but can be confirmed with computed tomography or magnetic resonance imaging 3
Treatment and Management
- Lateral canthotomy and cantholysis (LCC) is typically performed when IOP is elevated or vision is compromised 2
- LCC permits the quickest possible decompression after injury, thus temporarily reducing IOP, and orbital septum release consolidates the decompression by permitting hematoma drainage and identification and hemostasis of the bleeding point 4
- Surgical management aims to reduce IOP with surgical decompression or pharmacologic measures 3
- Combined surgical and medical therapy can achieve the best visual outcomes 5
Visual Outcomes and Prognosis
- Visual acuity at presentation is the most reliable predictor of visual acuity after follow-up 2
- The presence or absence of an afferent pupillary defect is the most sensitive indicator of optic nerve compromise and necessity for intervention 5
- Timely decompression of the orbit is crucial to prevent permanent vision loss 5