Management of Supraorbital Hematoma
For supraorbital hematomas, immediate assessment of visual function and hemodynamic stability is critical, with urgent surgical evacuation required within 60-100 minutes if vision-threatening orbital compartment syndrome develops. 1, 2
Initial Assessment and Stabilization
Immediately assess for orbital compartment syndrome (OCS) by checking:
- Visual acuity in both eyes 3, 4
- Pupillary response and presence of relative afferent pupillary defect 3, 2
- Intraocular pressure (elevated >40 mmHg suggests OCS) 3
- Proptosis, globe displacement, and extraocular movement restriction 4
- Pain with eye movements 5, 4
Check hemodynamic status using ATLS classification to determine if this is an isolated injury or part of polytrauma requiring broader resuscitation 1. Obtain large-bore IV access if hemodynamically unstable 1.
Obtain baseline coagulation studies (PT, aPTT, INR, platelet count) and immediately reverse any anticoagulation if present using prothrombin complex concentrates for warfarin or specific reversal agents for NOACs 1.
Imaging Strategy
For hemodynamically stable patients, obtain CT orbits without and with contrast to characterize the hematoma location (subperiosteal vs retrobulbar), size, and rule out associated orbital fractures or ongoing bleeding 6, 7. CT is preferred over MRI for acute trauma due to speed and availability 6.
If hemodynamically unstable with suspected polytrauma, perform FAST examination and consider whole-body CT if the patient can be stabilized for transport 6, 7.
Ultrasound has limited sensitivity and should not be relied upon to exclude significant pathology 7, 8.
Management Algorithm Based on Clinical Presentation
Vision-Threatening Hematoma (OCS Present)
Urgent surgical decompression is required within 60-100 minutes of symptom onset to prevent irreversible optic nerve damage and retinal ischemia 3, 2. Signs requiring immediate intervention include:
- Decreased visual acuity 9, 3, 4
- Afferent pupillary defect 3
- Proptosis with tense orbit 4
- Elevated intraocular pressure 3
Surgical evacuation should be performed through the most direct approach - either through existing laceration or via lateral canthotomy with cantholysis for retrobulbar hematomas, or direct incision for subperiosteal collections 4, 2. Adjunctive medical therapy includes mannitol, acetazolamide, and corticosteroids to reduce intraocular pressure 3.
Non-Vision-Threatening Hematoma
For patients with intact vision, normal pupillary response, and no signs of compartment syndrome:
- Admit for close monitoring with serial neurologic and ophthalmologic examinations every 2-4 hours 1, 2
- Apply ice and elevate head of bed 1
- Monitor for progressive swelling, declining visual acuity, or development of compartment syndrome 1
- Consider repeat imaging at 24 hours if clinical deterioration occurs 2
Most subperiosteal hematomas without visual compromise can be managed conservatively with observation 2.
Special Considerations
Spontaneous subperiosteal hematomas can occur without trauma in patients with chronic sinusitis, bleeding diathesis, or sudden increases in venous pressure 5. These patients require IV antibiotics if sinusitis is present and may still need surgical drainage if vision-threatening 5.
Delayed presentation does not preclude surgical intervention - visual recovery has been documented even after prolonged compression, though immediate decompression remains optimal 9. However, maintaining the 100-minute window is challenging in practice, with average time to surgery often exceeding 46 hours in delayed diagnoses 2.
Critical Pitfalls to Avoid
Do not delay surgical intervention in patients with visual symptoms while awaiting additional imaging or specialty consultation - the optic nerve tolerates increased pressure for only 60-100 minutes 3, 2.
Do not rely solely on absence of lid ecchymosis to exclude significant hematoma - subperiosteal hematomas characteristically present with proptosis and chemosis without external bruising 4.
Do not discharge patients on anticoagulation with negative initial imaging without observation period - delayed hemorrhage can occur, particularly in anticoagulated patients 6, 1.
Arrange follow-up within 48-72 hours for conservatively managed patients to reassess for delayed complications 1.