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Visual outcomes after traumatic retrobulbar hemorrhage are not related to time or intraocular pressure
Abstract
Background:
The paucity of literature regarding the role of time and intraocular pressure (IOP) when treating ocular compartment syndrome (OCS) has resulted in limited guidance for emergency physicians (EP).
Objectives:
Our goals were to investigate the ideal time frame for lateral canthotomy, to understand the relationship between IOP and visual outcome, and to determine the impact of EP performance on visual acuity (VA).
Methods:
The study population included patients presenting over an 18-year period with traumatic retrobulbar hemorrhage (RBH) treated with lateral canthotomy. Efficacy was evaluated using visual outcome and IOP. Patients were grouped by time from injury and arrival to canthotomy. Procedures completed in the emergency department (ED) and by EPs were evaluated regarding visual outcome.
Results:
Sixty cases of RBH treated with lateral canthotomy were identified. Over two-thirds (43/60, 71.7%) were discharged with baseline vision. Lateral canthotomy lowered IOP from a median of 50.0 mmHg (IQR: 40.5, 61) preprocedure to 23.0 mmHg (IQR: 18, 27) post-procedure (p-value = 0.000001). No correlation was found between time, IOP, location, specialty of clinician, and visual outcome.
Conclusion:
Lateral canthotomy is an effective at lowering IOP. Our data suggest that using time and IOP to predict procedural outcome is flawed. If OCS is suspected, lateral canthotomy should be considered and can be effectively performed by EPs. Neither the time of injury to ED presentation nor degree of IOP elevation should be factored into the decision of when to perform the procedure.
... To prevent permanent vision loss, prompt decompression is required, typically by lateral canthotomy and inferior cantholysis [1][2][3][4][5]. As visual sequelae may occur after only 60 min of elevated orbital compartment pressure (OCP), intervention is often required from emergency physicians or other non-ophthalmologists, even in prehospital settings [1,[5][6][7][8][9][10][11][12]. ...
... The need for additional diagnostic capabilities and guidance is often expressed by non-ophthalmologists, who are frequently the first care providers in cases of facial trauma [6][7][8][9]. Studies have shown that emergency physicians are particularly reluctant to perform lateral canthotomy, as they feel insecure when interpreting the clinical ophthalmological signs and believe they need more training to diagnose OCS correctly [6,8,10]. ...
... The need for additional diagnostic capabilities and guidance is often expressed by non-ophthalmologists, who are frequently the first care providers in cases of facial trauma [6][7][8][9]. Studies have shown that emergency physicians are particularly reluctant to perform lateral canthotomy, as they feel insecure when interpreting the clinical ophthalmological signs and believe they need more training to diagnose OCS correctly [6,8,10]. Thus, a practical and safe modality for a direct OCP measurement would be of great value. ...
Background
Diagnosis of orbital compartment syndrome is mainly based on clinical findings, such as intraocular pressure and proptosis, which try to estimate the orbital compartment pressure. However, the reliability of these surrogates is unclear. Current techniques for the direct measurement of orbital compartment pressure are widely experimental and impractical in the clinical setting. Our aim was to explore the feasibility of minimally invasive needle manometry for direct measurement of orbital compartment pressure under reproducible conditions in an in vivo model of orbital congestion. We further sought to evaluate intraocular pressure and proptosis as indicators for elevated orbital compartment pressure.MethodsA total of 7 ml of mepivacaine 2% solution was injected into the orbital compartment in 20 patients undergoing cataract surgery under local anesthesia. A commercially available single-use manometer device was inserted between the syringe and the injection needle to measure the orbital compartment pressure for each milliliter of intraorbital volume increment. Additionally, intraocular pressure (subgroup A; n = 10) or axial globe position (subgroup B; n = 10) were measured.ResultsNeedle manometry allowed for rapid and continuous measurement of orbital compartment pressure. Overall mean orbital compartment pressure increased from 2.5 mmHg pre- to 12.8 mmHg post-interventionally. Both, intraocular pressure (Spearman’s correlation coefficient rs = 0.637, p < 0.0001) and proptosis (rs = 0.675, p < 0.0001) correlated strongly with the orbital compartment pressure.Conclusions
Needle manometry appears to be a feasible minimally invasive instrument to directly measure orbital compartment pressure, showing promises for a more routine application in managing orbital compartment syndrome. The results further suggest that both elevated intraocular pressure and proptosis are valuable indicators for orbital compartment syndrome.
... In case of suspected orbital compartment syndrome with potential vision loss, surgical decompression must not be delayed and the indication for surgical intervention should be made at a low threshold [1,2,30,45,50,51]. However, studies have shown that emergency physicians, who are often the first to provide care in cases of facial trauma, are particularly reluctant to perform lateral canthotomy, as they feel insecure when interpreting clinical ophthalmological signs and believe they need more training to diagnose orbital compartment syndrome correctly [52][53][54]. Thus, the need for additional diagnostic capabilities and guidance is often expressed by non-ophthalmologists [49,52,53]. ...
... However, studies have shown that emergency physicians, who are often the first to provide care in cases of facial trauma, are particularly reluctant to perform lateral canthotomy, as they feel insecure when interpreting clinical ophthalmological signs and believe they need more training to diagnose orbital compartment syndrome correctly [52][53][54]. Thus, the need for additional diagnostic capabilities and guidance is often expressed by non-ophthalmologists [49,52,53]. A practical and safe modality for directly measuring OCP would therefore be of great value. ...
The orbit is a closed compartment defined by the orbital bones and the orbital septum. Some diseases of the orbit and the optic nerve are associated with an increased orbital compartment pressure (OCP), e.g., retrobulbar hemorrhage or thyroid eye disease. Our aim was to review the literature on the different approaches to assess OCP. Historically, an assessment of the tissue resistance provoked by the retropulsion of the eye bulb was the method of choice for estimating OCP, either by digital palpation or with specifically designed devices. We found a total of 20 articles reporting direct OCP measurement in animals, cadavers and humans. In nine studies, OCP was directly measured in humans, of which five used a minimally invasive approach. Two groups used experimental/custom devices, whilst the others applied commercially available devices commonly used for monitoring the compartment syndromes of the limbs. None of the nine articles on direct OCP measurements in humans reported complications. Today, OCP is mainly estimated using clinical findings considered surrogates, e.g., elevated intraocular pressure or proptosis. These diagnostic markers appear to reliably indicate elevated OCP. However, particularly minimally invasive approaches show promises for direct OCP measurements. In the future, more sophisticated, specifically designed equipment might allow for even better and safer measurements and hence facilitate the diagnosis and monitoring of orbital diseases.
... Cantholysis is generally advised to do within 24 hours after the onset of the proptosis, but we have seen patients with a complete recovery of visual functions, who had been operated after more than 24 hours. So, it is worth the effort to do a cantholysis in any patient with a tight orbit [11]. The significance of a cantholysis in a tight orbit is comparable to a tracheotomy in obstructed airways. ...
An orbital emergency is a situation in which visual functions can be lost in hours to days, because of injury to the optic nerve. The most common are traumatic optic neuropathy and retrobulbar hemorrhage.
... [2,37,52,71]. Dixon et al. [72] compared the "early canthotomy," which had been performed less than 3 h from symptom onset, to "late canthotomy" (performed after 3 h) group. Significantly more patients discharged with baseline vision in the "early canthotomy" group (80.4% versus 9.7%, p < 0.001), while fewer suffered complete visual loss (4.3% versus 48.4%, p < 0.001). ...
Purpose
Blindness in craniomaxillofacial (CMF) injuries may occur due to acute orbital compartment syndrome (AOCS). Primarily, this article aimed to retrospectively review our 4-year experience in the management of patients diagnosed with AOCS secondary to an orbital hematoma (OH). Furthermore, this paper included up-to-date information regarding the prevalence, diagnosis, management, and prognosis of AOCS.
Materials and methods
We retrospectively screened the medical records of patients who visited our hospital’s emergency department (ED) and were examined by an oromaxillofacial surgeon for CMF injuries, between September 1, 2013, and September 31, 2017. The electronic hospital’s database was searched to retrieve all cases of CMF trauma admitted or referred to our clinic during this period.
Results
Over a 49-month period, 3,514 patients were managed for CMF injuries in ED; 9 cases (0.26%) were attributed to OCS caused by an OH. This group comprised 5 males and 4 females aged between 32 and 91 years old (mean 65.7, median 70). Seven out of 9 patients were subjected to lateral canthotomy and inferior cantholysis (LCIC), whereas septolysis was applied in 6 of them. Sight was preserved in 3 out of 8 patients (37.5%), since a patient died from a serious intracranial injury. Seven out of 9 patients (77.7%) of the OCS group had a history of hypocoagulable state.
Conclusions
LCIC, septolysis, and careful dissection within inferotemporal orbital quadrant constitute a reliable approach for emergent orbital decompression. CT scan offers differential diagnosis of acute traumatic proptosis, but it should preferably follow LCIC. In case of OHs without pupillary abnormalities and/or impairment of visual acuity, close monitoring allowing for timely interventions is highly recommended to patients with a history of hypocoagulative status, (uncontrolled or severe) hypertension, head trauma, and decreased level of consciousness or in elderly patients suffering from dementia or without rapid access to follow-up medical care. Clinicians dealing with ED services must maintain high skills in AOCS diagnosis and in LCIC execution.
... 20 Furthermore, Bailey et al determined that 60% had improvement in vision with LCIC beyond 3 hours. 4 There are reports of vision recovery after delayed decompression,4,20,[43][44][45][46][47] even up to 5 days.48 ...
Orbital compartment syndrome (OCS) is a rare, vision‐threatening diagnosis that requires rapid identification and immediate treatment for preservation of vision. Because of the time‐sensitive nature of this condition, the emergency physician plays a critical role in the diagnosis and management of OCS, which is often caused by traumatic retrobulbar hemorrhage. In this review, we outline pearls and pitfalls for the identification and treatment of OCS, highlighting lateral canthotomy and inferior cantholysis (LCIC), a crucial skill for the emergency physician. We recommend adequate preparation for the diagnosis and procedure, early consultation to ophthalmology, clear and thorough documentation of the physical examination, avoidance of iatrogenic injury during LCIC, and complete division of the inferior canthal tendon. Emergency physicians should avoid failing to make the diagnosis of OCS, delaying definitive surgical treatment, overrelying on imaging, failing to decrease intraocular pressure, and failing to exclude globe rupture. The emergency physician should be appropriately trained to identify signs and symptoms of OCS and perform LCIC in a timely manner.
A 37-year-old old man presented with diplopia and reduction in left-side vision, following a blunt injury to his left eye caused by being beaten in a fight five days previously. His left visual acuity was hand motion. Computer tomography findings confirmed the presence of a retrobulbar hemorrhage. Ten minutes after the start of the consultation (6 hours after onset of vision loss), urgent lateral canthotomy and cantholysis were performed and left visual acuity was improved promptly from hand motion to count fingers. Thirty minutes later, an ophthalmologic examination revealed left visual acuity of 0.5 (right visual acuity was 1.5). Six hours later, the patient underwent endoscopic left orbital decompression under general anesthesia. One month postoperatively, left visual acuity had improved to 1.2 and diplopia had disappeared. There are previous reports of patients with periorbital trauma without decreased visual acuity who developed delayed retrobulbar hemorrhage. Therefore, adequate follow up for a certain period is recommended, and orbital decompression surgery, including lateral canthotomy and cantholysis, should be performed as early as possible if retrobulbar hemorrhage is suspected.
Background:
Evaluation of orbital pressure is crucial for monitoring various orbital disorders. However, there is currently no reliable technique to accurately measure direct orbital pressure (DOP). This study aimed to establish a new method for the DOP as well as to verify its repeatability and reproducibility in rabbits.
Methods:
The study included 30 normal eyes from fifteen 3-month-old New Zealand white rabbits. After administering inhalation anesthesia, intraocular pressure (IOP) was determined by tonometry (Tonopen). For DOP manometry, a TSD104 pressure transducer was inserted between the disposable injection needle and the syringe, and the output results were displayed on a computer. Two observers independently participated in the experiment to verify its repeatability and reproducibility.
Results:
The mean IOP of rabbits was significantly higher than the DOP in normal rabbits (11.67 ± 1.08 mm Hg versus 4.91 ± 0.86 mm Hg, P < 0.001). No significant interocular difference was detected for both IOP and DOP (P > 0.05). A high correlation was found for intraobserver measurements of both IOP (intraclass correlation coefficient = 0.87, P < 0.001) and DOP (intraclass correlation coefficient = 0.89, P < 0.001). A high agreement was also presented for the interobserver reproducibility for the measurements of IOP [Pearson correlation coefficient (R) = 0.86, P < 0.001] and DOP (R = 0.87, P < 0.001). Direct orbital pressure was positively correlated with IOP in both observers (R1 = 0.66, R2 = 0.62, P < 0.001). The Bland-Altman plots revealed that 5.0% (3/60) of the IOP and DOP measurement points were outside of the 95% limits of agreement, respectively.
Conclusions:
The TSD104 pressure transducer-based manometry may serve as a reliable device for the measurement of DOP, providing real-time measuring results with acceptable reproducibility and repeatability.
Spontaneous retrobulbar hemorrhage (RBH) is uncommon and typically occurs secondary to vascular malformations, coagulopathies, hypertension, or strenuous activities in the setting of elevated intraocular pressure (IOP). RBH can cause orbital compartment syndrome (OCS) with resultant permanent vision loss. We present a case of spontaneous RBH in an 18-year-old male with a history of acute lymphoblastic leukemia (ALL) and sepsis. While IOPs were normal, the patient exhibited symptoms of OCS in which a lateral canthotomy and cantholysis were performed. This case highlights the importance of the clinical exam when treating a patient with suspected OCS and demonstrates that intraocular pressures need not be elevated for both diagnosis and intervention.
Rarely, but often with serious consequences for the patient, the optic nerve is affected during the course of head injuries. Traumatic optic nerve compression is always an emergency situation, which is why time is of the essence for both diagnosis and treatment. Precise knowledge of this accident sequelae but also of the resulting conditions, especially in terms of traumatic optic neuropathy, is indispensable for adequate patient care. The aim of this paper is to provide an overview of this clinical picture, particularly with regard to etiology, diagnosis, and treatment options, and to discuss this in the context of the current literature.
Purpose
Retrobulbar hematoma (RBH) is a rare but serious vision threatening emergency. We analyze relationship between hematoma volume, visual impairment and outcome.
Methods
54 patients with RBH receiving orbital decompression were retrospectively included. Volumetric analysis of RBH was performed by semi-automatic segmentation based on preoperative CT scans using ITK-SNAP software. Best corrected visual acuity (BCVA) measurements were obtained and correlated in 2 groups (No light perception (NLP), severe visual impairment) with the hematoma volume.
Results
NLP was documented preoperatively in 5/28 and postoperatively in 9/43 patients. Preoperative NLP was significantly associated with a larger hematoma volume (p=0.03) and higher hematoma/orbital volume ratio (p=0.03). Postoperative severe visual impairment showed significant associations with a larger hematoma volume (p=0.02) as well as higher hematoma/orbital volume ratio (p=0.02).
Conclusion
Eyes with severe visual impairment and large hematoma volumes preoperatively are at high risk of permanent vision loss. Hematoma volume calculation might represent an additional prognostic parameter for visual outcome after RBH.
Introduction
Acute retrobulbar haemorrhage (RBH) with orbital compartment syndrome is a sight-threatening ophthalmic emergency requiring treatment with lateral canthotomy and cantholysis (LC/C). However, such cases may present to non-ophthalmic emergency departments (ED) out-of-hours, when specialist intervention is not readily available. We completed a survey of ED physicians to explore experiences of RBH and confidence in undertaking LC/C.
Methods
From February to April 2018, an online survey was sent to ED physicians of all training grades in seven UK locations. The survey comprised a case vignette of a patient presenting with clinical features of RBH with orbital compartment syndrome, with multiple choice questions on the diagnosis, management and onward referral of such cases. Additional questions explored the experience of RBH, LC/C and perspectives on current and future training of ED physicians in this area.
Results
190 ED doctors completed the survey (response rate 70%). While 82.8% correctly diagnosed RBH and 95.7% recognised irreversible visual loss as a consequence of untreated RBH with orbital compartment syndrome, 78.7% indicated that they would initially undertake CT imaging rather than performing LC/C. Only 38.9% had previously encountered a case of RBH and only 37.1% would perform LC/C themselves, with 91.4% indicating that this was due to lack of training. 92.2% felt that more training was required for ED physicians in RBH management and performing LC/C.
Conclusion
While cases of RBH with orbital compartment syndrome are infrequent, it is important that RBH management with the vital, sight-saving skill of LC/C is added to the United Kingdom Royal College of Emergency Medicine training curriculum. At present, though the majority of ED physicians can identify RBH, the minority are willing or able to undertake LC/C, potentially risking irreversible but avoidable visual loss.
orbital compartment syndrome is an emergency that should be well known by all ophthalmologists
The objective of this study was to determine the effect of orbital decompression procedures on the intraocular pressure (IOP). The orbital compartment syndrome represents an emergency situation. Due to the elevated IOP vision loss may ensue. Several maneuvers including lateral canthotomy are discussed to reduce the IOP. Eight orbits were studied in a fresh frozen cadaveric model (4 specimens). Intraorbital volume was determined by CT volumetry. An orbital compartment syndrome was simulated by injecting viscous material into the orbit. Injected volumes were documented and lateral canthotomy, cantholysis, inferior and superior septolysis were performed. IOP and exophthalmometric measurements were obtained after each intervention. Controlled elevation of IOP was achieved in all specimens. IOP was partially reduced after performing a lateral canthotomy in eight orbits. IOP was significantly and sufficiently decreased under 20 mmHg by inferior cantholysis in seven orbits. An additional superior cantholysis was necessary in two orbits to achieve a complete decompression. Inferior or superior septolysis were not needed to further reduce the IOP. Lateral canthotomy must be followed by an inferior cantholysis to successfully decompress an orbital compartment syndrome in the majority of cases. Occasionally, superior cantholysis may generate additional benefit. Additional inferior and superior septolysis were not shown to provide a beneficial effect when performed after canthotomy and cantholysis.
Retrobulbar haemorrhage is a sight-threatening condition that can occur after orbital trauma. The aim of this study was to evaluate the frequency and outcome of orbital haemorrhages following orbital fractures in geriatric patients receiving anticoagulants. All patients aged 65 years or more suffering from orbital fractures between 2008 and 2009 were included in this study. The mechanism of trauma, underlying diseases, and medication were recorded. In case of a retrobulbar haemorrhage, surgical exploration, the elapsed time between the onset of haemorrhage symptoms and surgical treatment, and the outcome regarding visual acuity were documented. Sixty-eight orbital fractures occurred (31 males, 37 females, age 65-95 years) resulting in six (3%) orbital haemorrhages. Four cases were associated with initial orbital bleeding, two other patients developed orbital haemorrhage as a complication after surgical reconstruction. Anticoagulant therapy, but not aspirin, was associated with a significantly increased risk of retrobulbar haematoma (p=0.02). Two patients permanently lost vision, two partial recoveries and two total recoveries were observed. Patients receiving anticoagulants have a higher risk of orbital haemorrhage after orbital fracture and should be monitored closely. Any evidence of visual impairment should lead to further investigation and prompt treatment.
Acute retrobulbar haemorrhage is a potentially sight-threatening condition, and can follow retrobulbar anaesthesia or trauma to the orbit. Acute loss of vision can occur with retrobulbar haemorrhage and is reversible if the condition is recognised and treated early.
We report a case of acute retrobulbar haemorrhage following orbital trauma in a 78-year-old Chinese lady.
The patient was on follow-up for a mature cataract in the right eye and had been scheduled for cataract surgery. The patient presented to the emergency department with acute loss of vision in the right eye, severe proptosis and tense periorbital haematoma after she hit her right face following a fall. Computed tomography scans revealed fractures of the floor, lateral and medial walls of the right orbit as well as retrobulbar and periorbital haematoma. There was marked proptosis and tenting of the globe with stretching of the optic nerve. Emergent lateral canthotomy and cantholysis was performed at the emergency department. The patient subsequently underwent surgical evacuation of the orbital haematoma.
The patient's vision in the right eye recovered from no perception of light to light perception over the next few days. After a month of follow-up, the patient underwent right cataract surgery, and her best corrected visual acuity was 6/12 part.
In severe acute retrobulbar haemorrhage, prompt surgical evacuation of the haematoma can reverse visual loss.
Lateral canthotomy and cantholysis is a simple procedure that can be performed by emergency physicians. It has the potential to save vision, particularly in cases of blunt ocular trauma. The case of a 37-year-old man with blunt ocular trauma, a retrobulbar hemorrhage and rapidly increasing orbital pressure requiring an urgent lateral canthotomy and cantholysis is presented. Pathophysiology, indications, contraindications, procedure and follow-up care are described.
Acute retrobulbar haemorrhage (ARBH) is a rare ophthalmic emergency observed following blunt eye trauma. Multiple trauma and loss of consciousness can hide symptoms of ARBH. Rapid diagnosis and immediate lateral canthotomy and cantholysis must be performed to prevent permanent visual loss in patients. Medical treatment can be added to surgical therapy. Lateral canthotomy and cantholysis are simple procedures that can be performed by emergency physicians. In this report, it was aimed to present a case with post-traumatic ARBH and provide general knowledge about the diagnosis, follow-up and treatment of ARBH.
Orbital compartment syndrome is an acute rise in intraorbital volume resulting in increased intraorbital pressure and possible ischemic compromise of the optic nerve. Tonometric pressure measurement of intraocular pressure can aid surgeons in the diagnosis of this condition and in choosing the need to proceed with emergent surgical intervention. In addition, we present an unexpected cause of orbital compartment syndrome following routine frontal sinus irrigation.
An emergent lateral canthotomy and cantholysis followed by endoscopic medial wall decompression were performed, with intraocular pressure measurements performed throughout the evolution of this successful, and vision sparing, set of procedures. The techniques and continuous improvements in intraocular pressure measurements are described.
There are only rare reports of the progression of intraocular pressure prior to, and concurrent with, surgical orbital decompression. While no absolute threshold for intraocular pressure exists for when surgical decompression should be performed, the decision of when and which decompression procedures to undertake should be based on clinical judgment and experience. Availability of tonometry in the operating room serves to measure response to management in these rare but challenging settings where intervention may be required to prevent irreversible visual loss.
Orbital compartment syndrome is a sight-threatening emergency. Vision may be preserved when timely intervention is performed.
To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration.
Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome.
Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss.
Copyright © 2014 Elsevier Inc. All rights reserved.
Retrobulbar hemorrhage is a rare but potentially devastating complication of mid-face trauma. Management of this entity requires prompt diagnosis as well as medical and surgical intervention Incidence of retrobulbar hemorrhage has been cited to be less than1%; however, despite a low rate of occurrence, lack of immediate care can lead to significant morbidity for the patient. Purpose of this manuscript is a retrospective evaluation of the incidence and management of post-traumatic retrobulbar bleed in the emergency department by the by the oral and maxillofacial surgery service at a tertiary care trauma center.
Retrobulbar hemorrhage is an uncommon, vision-threatening complication of orbit and eyelid surgery. We review the incidence of retrobulbar hemorrhage, risk factors, orbital anatomy, pathophysiology, diagnosis and treatment options. Preoperative, intraoperative and postoperative measures to prevent retrobulbar hemorrhage are discussed, and a treatment algorithm is presented.
Background
Orbital compartment syndrome (OCS) is an ophthalmic emergency that requires urgent surgical decompression to preserve vision.Objective
To describe the clinical presentation, management and outcomes for patients with traumatic OCS.Methods
Retrospective case series of eight patients with OCS secondary to blunt trauma presenting to the Royal Adelaide Hospital between 2004 and 2013.ResultsAll patients had acute, painful decrease in visual acuity and proptosis. Common examination findings included a relative afferent pupillary defect, periorbital oedema, ophthalmoparesis and chemosis. All patients underwent surgical decompression in the form of a lateral canthotomy or cantholysis. Three patients who were decompressed within 2 h after injury recovered fully. One patient who sustained a macular hole at the time of injury recovered four lines of Snellen acuity after being decompressed within 1 h. Another patient recovered three lines of Snellen acuity after undergoing decompression at 2.5 h post-injury. The remaining patients had minimal visual recovery, with postoperative visual acuities ranging from hand movements to no perception to light. Of these patients, one was decompressed at 2 h, while the remaining underwent decompression at 4 and 6 h post-injury.Conclusions
Prompt decompression is essential for visual recovery in OCS, which appears maximal if performed within 2 h of injury. All patients presenting with history and examination findings suggestive of OCS should undergo emergency canthotomy and cantholysis prior to any additional investigations to minimise visual loss.
Objectives:
Retrobulbar hemorrhage is a rare condition often necessitating immediate lateral canthotomy for preservation of vision. It is performed infrequently in emergency departments (EDs); therefore, a laboratory-based curriculum using a swine model was developed to teach emergency medicine (EM) residents and pediatric emergency medicine (PEM) fellows the proper technique of lateral canthotomy and to provide them with hands-on training.
Methods:
Anesthetized adult swine are used due to similarity with human anatomy and availability from other concurrent procedure laboratories. Fifteen to twenty milliliters of saline is injected behind the orbit to produce proptosis and mimic retrobulbar hemorrhage. A dissection is performed on one orbit to demonstrate the technique and to illustrate the lateral canthal ligaments. The resident then performs a rapid lateral canthotomy on the contralateral orbit under faculty supervision.
Results:
Over one year, 19 EM residents and 3 PEM fellows were trained using this model. During the same period no lateral canthotomies were performed in the EDs. A post-laboratory survey demonstrated a high subjective level of comfort with this procedure. Video-based demonstration of this laboratory is publicly available on the World Wide Web.
Conclusion:
Adult swine can effectively serve as a model for resident training in lateral canthotomy, a rarely performed sight-saving procedure.
Retrobulbar haematoma formation is a known complication following facial trauma involving the orbits. This is an important clinical entity as it can lead to permanent vision loss if not appropriately managed in the acute setting.
From 1999 to 2009, 2586 patients presented to the Chang Gung Memorial Hospital with orbital fractures. Eight patients presented with nine retrobulbar haematomas. A retrospective review of the patient's medical records was performed. Analysis of visual outcomes was performed based on the improvement degree (ID) formula.
The average age of our patients is 24.5 years with the most common cause of trauma being motor vehicle (motorcycle) collisions. Visual acuity and the light reflex were abnormal in all patients. Five patients (case #1-5) demonstrated an absent relative afferent pupillary defect (RAPD). Computed tomography imaging confirmed the presence of a retrobulbar haematoma in all patients. The average follow-up was 14.5 months (range: 6-20 months). Management was divided into three cohorts: observation alone, medical therapy alone or a combined surgical and medical therapy. The best visual outcomes (ID = 82%) were achieved in the combined treatment group. The worst outcomes (ID = 42%) were in the medical therapy alone group.
In review of our experience, we have found that the presence or absence of an RAPD is the most sensitive indicator of optic nerve compromise and necessity for intervention. An algorithm was also developed based on this study. Once a decision is made to intervene on a retrobulbar haematoma, both medical and surgical therapies should be instituted with a priority given to timely decompression of the orbit.
While the implementation of deep vein thrombosis (DVT) prophylaxis in the hospital setting is a major concern, the use of antithrombotic agents is fraught with a variety of hemorrhagic complications. Due to increasing reports of adverse reactions to unfractionated heparin (UFH), several manufacturers have initiated product recalls. As a result, the use of low-molecular weight heparins (LMWHs) such as enoxaparin has risen substantially. In this paper, 2 orbital hemorrhagic complications in patients receiving enoxaparin therapy will be presented. The incidence of DVT in the OMS patient, recent prophylactic strategies, and their effectiveness will be reviewed.
To review the nature and outcomes of acute severe proptosis in patients after craniofacial trauma, over a 6-year period.
These were identified prospectively. The mechanism of injury, nature of the proptosis, and visual outcomes in each case were reviewed. Review of the literature was undertaken.
In all cases proptosis, was secondary to retrobulbar edema and not hemorrhage.
Many cases of "retrobulbar hemorrhage" may, in fact, be secondary to edema. This has significant implications when managing the proptosed eye on an emergent basis. Possible reasons for poor outcomes are discussed. A number of unanswered questions arise from this review.
Transient central retinal artery occlusion (CRAO) was produced in 63 eyes of rhesus monkeys by lateral orbitotomy and temporary clamping of the central retinal artery (CRA) for between 15 and 270 minutes. Thirty-three eyes were examined at regular intervals for 12 to 22 weeks. Color fundus photography, fluorescein fundus angiography, electroretinography (ERG) and visual evoked response (VER) were performed before and during clamping of the CRA as well as periodically after unclamping. All the eyes were examined by light and/or electron microscopy. This study revealed that the retina suffered irreparable damage after ischemia of 105 minutes, but recovered well after ischemia of 97 minutes. As a general rule, the monkey retina can tolerate up to 100 minutes of ischemia but not more.
Retrobulbar haemorrhage is a rare complication following orbital trauma or surgery occurring in less than 1 per cent of cases. Early diagnosis and treatment of this complication may save the vision of the affected eye. This paper illustrates cases where diagnosis was not made and blindness resulted. We also present two cases of successful treatment due to early diagnosis.
Blindness after facial fractures has been reported to occur with an incidence that ranges between 0.67% and 3% depending on the reporting institution. To verify this finding we undertook a retrospective chart review of 5936 patients with facial fractures that occurred over a 12 1/2-year period. We found that vision in 19 eyes were lost in 18 patients. Vision loss was more frequently encountered in Le Fort III level fractures (2.2%) followed distantly by Le Fort II level fractures (0.64%), and zygomatic fractures (0.45%). The cause of blindness was most frequently associated with motor vehicle accidents and gunshot injuries. Injuries of this type require immediate and prompt consultation by the ophthalmologic surgery service.
Retrobulbar haemorrhage is a rare complication of orbital injury or surgery. After injury the first clinicians to see these patients are often the staff of accident and emergency departments. This survey was instigated after several patients had been referred to our care irreversibly blind. A multiple choice questionnaire was devised and sent to 90 doctors working in accident and emergency departments in Scotland. A total of 57 (63%) were returned of which 55 were complete enough to analyse. The range of respondents was: consultants (n = 6), associate specialists (n = 3), senior registrars (n = 3), registrars (n = 4), senior house officer (n = 35), and clinical assistants (n = 4). Twenty nine of the 35 senior house officers (83%) were unable to diagnose and treat retrobulbar haemorrhage. Most consultants, senior registrars, registrars and associate specialists were significantly better in the diagnosis and treatment of this condition (P = 0.001). We conclude that there is an unacceptably high incidence of blindness as a result of inappropriate diagnosis and treatment of retrobulbar haemorrhage. We have therefore designed a protocol for accident departments which should help reduce the incidence of blindness.
Blindness associated with facial fracture repair is a devastating complication. Fortunately, its occurrence is rare. Orbital compartment syndrome resulting from retrobulbar hemorrhage is the leading cause of visual compromise after facial trauma surgery, with a reported incidence of 0.3% after zygomatic fracture repair.’ Other factors that may contribute to visual loss include direct intraoperative injury to the optic nerve from surgical manipulation, bony fragments, orbital implants, or inferior retinal arteriolar occlusion associated with postoperative orbital swelling.2,3 cial fracture repair in which the vision was salvaged by orbital and optic nerve decompression. Possible contributing factors to the postoperative blindness are discussed.
To report the observation of an acute traumatic orbital compartment syndrome in an 80-year-old man.
Lateral canthotomy and cantholysis. Computed x-ray tomography.
Unilateral proptosis, blindness, a frozen globe and a dilated pupil developed within one hour after a blunt trauma to the left orbital region. Surgery two hours later resulted in normal orbital tension and near-complete recovery of functions. An orbital hematoma was found overlying a lateral blow-out fracture.
Under favorable conditions, the orbital compartment syndrome can be effectively relieved by lateral canthotomy and cantholysis. The present and previous reports suggest that two hours of orbital ischemia is near the critical time limit for recovery of full visual function.
Retrobulbar haemorrhage (RBH) occurs in a variety of situations. It can complicate facial fractures, orbital surgery and retrobulbar injections and can occur spontaneously. It is relatively uncommon and sight-threatening RBH is even less common. If not detected early enough it can lead to devastating loss of vision. We have collected five cases of acute RBH, following trauma, associated with a profound reduction in vision. In each case a permanent loss of vision was avoided using a lateral canthotomy and inferior cantholysis approach to obtain urgent orbital decompression.
To evaluate the retinal tolerance time to acute ischemic insult in middle-aged or elderly rhesus monkeys with pre-existing atherosclerosis and arterial hypertension.
In 39 eyes of 39 middle-aged and elderly rhesus monkeys with a mean age of 19.5 +/- 2. 8 years, occlusion of the central retinal artery was produced by temporary clamping of the central retinal artery at its site of entry into the dural sheath of the optic nerve for 97 to 300 minutes. Stereoscopic color fundus photography and fluorescein fundus angiography were performed before central retinal artery occlusion and serially thereafter. Retinal nerve fiber layer damage and optic disk changes were assessed by comparing morphometric evaluation of the color fundus photographs taken before central retinal artery occlusion and color fundus photographs taken at the end of the study.
There was a significant correlation between duration of central retinal artery occlusion and decreased visibility of retinal nerve fiber layer (P =.018) and increasing optic disk pallor (P =. 014), and a trend between residual retinal circulation and decreased visibility of retinal nerve fiber layer (P =.085) and optic disk pallor (P =.162). However, there was a marked interindividual variation between the length of central retinal artery occlusion and degree of increased optic disk pallor and decreased visibility of the retinal nerve fiber layer, even among eyes with similar duration of central retinal artery occlusion. Complete or almost total optic nerve atrophy and nerve fiber damage were present in all eyes in which the duration of central retinal artery occlusion was 240 minutes or more.
The findings of this study, compared with our previous study in young healthy rhesus monkeys, indicate that in middle-aged or elderly atherosclerotic and arterial hypertensive rhesus monkeys, central retinal artery occlusion for less than 100 minutes produced no apparent morphometric evidence of optic nerve damage; however, central retinal artery occlusion of 105 minutes but less than 240 minutes produced a variable degree of damage; central retinal artery occlusion for 240 minutes or more produced total or almost total optic nerve atrophy and nerve fiber damage.
Traumatic retrobulbar hemorrhage may result in acute loss of vision that is reversible when recognized and treated promptly. A case of traumatic retrobulbar hemorrhage is presented. The technique of emergent orbital decompression by lateral canthotomy and cantholysis is described. The anatomy of the lateral canthus and the surgical procedure are illustrated by gross dissection.
To investigate the retinal survival time following central retinal artery occlusion (CRAO).
In 38 elderly, atherosclerotic and hypertensive rhesus monkeys, transient CRAO (varying from 97 to 240 min) was produced by temporarily clamping the CRA at its site of entry into the optic nerve. Stereoscopic color fundus photography, fluorescein fundus angiography, electroretinography (ERG), and visual evoked potential (VEP) recording were performed before and during CRA clamping, after unclamping, and serially thereafter. After unclamping of the CRA, the animals were followed for variable lengths of time (median duration 8.14 weeks). Finally, the eyes and optic nerves were examined histologically. The data on ERG changes were analyzed in the following four time frames: (1) baseline before CRA clamping, (2) during CRA clamping, (3) immediately after unclamping, and (4) at the end of follow-up. Duration of CRAO was divided into four groups: 97, 105-120, 150-165, and > or = 180 min.
A 'negative ERG' appeared during CRA clamping. With removal of the CRA clamp, there was b-wave recovery, with differential rates of recovery of ERG-eyes with shorter CRAO recovered sooner than those with longer occlusion. On removal of clamp, recovery was seen in scotopic 24 dB b-wave, photopic 0 dB single flash b-wave and 30 Hz flicker, with the b/a ratio of the combined rod and cone response and selective rod response showing statistically significant differences amongst the shorter and longer periods of CRAO. A delayed normalization of the depressed b/a ratio immediately after CRA reperfusion may indicate high-grade ischemic damage. At the final follow-up test session, no clear-cut derangement of any ERG parameter was seen for any group, with subtotal b-wave amplitude recovery for all groups. Longer CRAO produced incomplete VEP recovery. On histology, in the macular retina, eyes with CRAO for 97 min showed practically no damage, but duration of CRAO was found to be significantly associated with the amount of damage in the ganglion cell layer (p = 0.009) and inner nuclear layer (p = 0.017). Outer nuclear and plexiform layers and photoreceptors showed no damage at all with CRAO. There was no significant association of the ERG measures and histologic changes with any of the residual retinal circulation variables.
Our electrophysiologic, histopathologic and morphometric studies showed that the retina of old, atherosclerotic, hypertensive rhesus monkeys suffers no detectable damage with CRAO of 97 min but above that level, the longer the CRAO, the more extensive the irreversible damage. The study suggests that CRAO lasting for about 240 min results in massive irreversible retinal damage.
To assess the effects of acute orbital volume changes after retrobulbar injection on optic nerve head topography.
The study population consisted of 95 patients with type 2 diabetes mellitus with clinically significant macular oedema who required focal pattern laser photocoagulation therapy in one eye. Before each laser treatment, 49 patients required a retrobulbar injection (approximately 7 ml of a mix of lidocaine 2% with epinephrine and bupivacaine 0.75% in equal volumes) to provide ocular akinesia. Both eyes of all patients underwent optic nerve head topographic analysis once before laser treatment (within 30 minutes), and repeated within 1 hour, 1 day, 1 week, 2 weeks, and 4 weeks after treatment, respectively. Topographic analyses were performed using a confocal scanning laser ophthalmoscope, HRT-II. The disc area, topography standard deviation, and a total of 12 topographic parameters were calculated by HRT-II.
The mean age of the patients was 37.9 (SD 3.2) years. The mean disc area of the subjects was 2.12 (0.44) mm(2). Fellow eyes which were not treated with laser, and those treated eyes which did not receive retrobulbar injection before therapy were found not to reveal significant changes in disc topography in any of the examinations (all p values >0.05). In the topographic examinations in the first hour, first day, and first week, laser treated eyes which underwent retrobulbar injection demonstrated significant increase in the disc area, rim area, rim volume, rim area/disc area, and cup shape measure parameters while optic cup parameters significantly decreased (all p values <0.05). In the second week examinations, they did not show significant difference in disc area measurements (p>0.05). By the fourth week, all of the optic nerve head topographic variables were not significantly different from the pre-injection values (all p values >0.05). Colour stereoscopic photographs did not reveal any differences in optic disc appearance.
Acute orbital volume change following retrobulbar injection may cause significant topographic evidence of optic disc oedema lasting approximately 1 week. Significant changes in optic rim and cup area may last for 2 weeks after injection, with all topographic changes returning to baseline by 1 month after injection. The present findings could be a model to reflect the pathological processes that occur in cases of acute orbital volume changes such as retrobulbar haemorrhage.
We conducted a 19-year review of patients with facial fractures who were treated in the Iranian Maxillofacial Unit at the Mobasher Emergency Hospital, Hamedan Province, Iran, to specifically consider those fractures that resulted in blindness or severe visual impairment.
During the period of February 16, 1984, to March 20, 2003, a total of 2,503 patients with facial fractures were operatively treated. Of these, 550 (22%) patients had orbital region fractures and were specifically studied.
From our facial fractures database, 83 (3.31%) patients were identified as having ocular or extraocular injuries. Of these, 39 patients (1.56%) had severe visual impairment or blindness.
Laterally directed forces are implied as major causative factors in blindness or visual impairment. Males (83.3%), left eye (63.3%), third and fourth age decades (53.3%), and motor vehicle accidents (63.3%) were the most commonly involved gender, site, age, and cause of monocular blindness, respectively.
Retrobulbar haematoma following blunt orbital trauma is a rare, but potentially serious, complication, since it can evolve rapidly from visual impairment to permanent loss of vision. This sight-threatening situation most commonly arises from orbital bleeding accompanying undisplaced fractures of the orbital walls, an event that increases the pressure inside the orbit and results in vascular damage to the optic nerve. The clinical presentation includes pain, exophthalmos with proptosis, and internal ophthalmoplegia, with impairment or loss of the pupillary reflex. A thin-layer orbital CT scan is an essential diagnostic aid. Any delay between the onset of symptoms and treatment can have a significant effect on functional recovery. Therapy is based on orbital decompression, via different surgical approaches, with the intention of reducing the pressure on the nerve and vascular structures inside the orbit. This paper presents eight cases of retrobulbar haematoma and their follow-up, in detail.
Delay in diagnosis and treatment of an elderly woman with a malar fracture that caused retrobulbar haemorrhage resulted in complete loss of vision in the right eye.
The orbit is a cone-shaped structure formed by rigid bony walls within which the globe and retrobulbar contents are encased. Anteriorly, the orbital septum and eyelids form another relatively inflexible boundary. The medial and lateral canthal tendons attach the eyelids to the orbital rim and also limit any anterior displacement of the globe. Although small increases in orbital volume can be compensated for by forward displacement of the globe and prolapse of fat, a rapid rise in intraorbital pressure normally ensues. This increase in pressure within the confined space of the orbit causes decreased perfusion with associated ischaemic damage not unlike that seen in other compartment syndromes. We report a case of traumatic orbital compartment syndrome successfully decompressed by means of a lateral canthotomy.
Incidence of retrobulbar hemorrhage in the emergency department.
- Fattahi T.
- Brewer K.
- Retano A.
Orbital haemorrhage associated with orbital fractures in geriatric patients on antiplatelet or anticoagulant therapy.
- Maurer P.
- Conrad-Hengerer I.
- Holstein S.
- Mizziani T.
Management of acute traumatic retrobulbar haematomas: a 10-year retrospective review.
- Chen Y.A.
- Singhai D.
- Chen Y.R.