What is Retrobulbar Hematoma?
Retrobulbar hematoma (RBH) is an uncommon condition that can threaten your vision. It develops when there’s a buildup of blood at the back of your eye socket. While some cases can be mild, it can lead to a severe complication called orbital compartment syndrome, which might cause complete vision loss if it’s not treated quickly. The recommended treatment for this condition is a procedure called lateral orbital canthotomy and cantholysis. This surgery could potentially save your vision.
What Causes Retrobulbar Hematoma?
A retrobulbar hematoma, which is a blood clot that forms behind the eye, usually occurs due to injury, particularly if the bottom part of the eye socket gets fractured. However, it can also happen as a side effect of sinus or eye surgeries. These incidents, though, are very few and far between. If we look at the numbers, for instance, a retrobulbar hematoma occurs in 2% of instances after an injection that numbs the area around the eye, 0.3% after surgery for a fractured cheekbone, and 0.055% after eyelid surgery.
There are very few cases where a retrobulbar hematoma develops due to a strong exhalation, like with a sneeze, especially in individuals who are on blood thinners. In fact, there’s a documented case where a 31-year-old woman, who experienced a headache and blurred vision after sneezing, was found to have this condition. It can also be caused by abnormal blood vessels, blood clotting disorders, and high blood pressure that isn’t being managed properly.
orbit after an uneventful upper blepharoplasty. The patient was not seen and
examined until the following morning when this photograph was taken. The patient
has no perception of light in the left eye. A canthotomy, cantholysis, and
evacuation of orbital hemorrhage did not help this patient, as this should have
been performed much earlier.
Risk Factors and Frequency for Retrobulbar Hematoma
Retrobulbar hematoma, a condition where blood collects at the back of the eye, can occur due to different reasons, and its occurrence rate varies. The percentage of people it affects can be less than 1% after surgery, or up to 4% in cases of trauma. In a study of 1,386 patients with facial injuries at a leading trauma hospital, it was found that 3.6% of the patients had retrobulbar hematoma. The rate of permanent blindness in these patients was 0.14%.
In another review of 426 patients who had surgery to fix a broken bone in the eye socket, the occurrence of retrobulbar hematoma after the surgery was 1.2%. All of the patients who developed this condition after the surgery were able to retain their normal vision. Other studies have reported retrobulbar hematoma occurrence rates of 0.6% and 0.055% after operations to rebuild the eye socket and surgery to reshape the eyelids, respectively.
Signs and Symptoms of Retrobulbar Hematoma
If someone has had a head injury, they may experience a range of symptoms related to their eyes. They might have had a severe injury that could potentially cause the eye to rupture. Other symptoms include double vision, headache, nausea, vomiting, pain around the eye, dark purple bruising around the eye, less clear vision, increased pressure inside the eye, swollen and bulging eye, problems moving the eye, and swelling of the optic nerve.
A thorough eye exam is important in these cases. This can include checking vision in each eye separately, responses to light, and eye movement. The ability to move one’s eye can tell us a lot about the state of the orbits, which are the bony sockets that hold the eyes.
Checking the pressure inside the eye is a crucial part of the exam. While we don’t generally measure the pressure in the orbit directly, as it involves a specialist procedure, related signs can give an indication of potential problems. For example, increased pressure inside the eye and bulging of the eye are strongly linked with pressure in the orbital compartment, warning of an impending orbital compartment syndrome, which is a serious condition.
It can be particularly challenging to assess these kinds of symptoms if the person is unconscious or unwilling to cooperate for the exam. This is further complicated if they have multiple injuries or if their consciousness is impaired. However, it is very important to gather as much information as possible to understand the severity of the injury and make a quick diagnosis. The doctor will check for symptoms like a bulging eye, resistance to pushing the eye back into the socket, how the pupils respond to light, the pressure inside the eye, and physical signs such as tension and swelling in the eyelids. These might indicate that the pressure inside the orbit has increased. If both signs of the optic nerve not getting enough blood (due to a retrobulbar hematoma, which is a collection of blood at the back of the eye) are present and the pressure in the eye is 40 mmHg or more, immediate treatment should start.
Testing for Retrobulbar Hematoma
Retrobulbar hematoma (RBH), a condition where blood collects at the back of the eye, can be diagnosed through a clinical exam. RBH cases vary in severity – some cases may be mild and cause no vision problems, while some could be severe, leading to orbital compartment syndrome (OCS), an eye emergency that results in painful pressure on the eye.
Reviewing medical records has shown that about one-third of fractures in the wall of the eye socket also have an associated RBH. In context, this was identified through a type of imaging scan called computed tomography (CT). However, only a tiny fraction (1.1%) of these cases needed intervention because of complications like OCS.
This information highlights the importance of a thorough clinical examination. With the help of CT imaging, doctors can see how far the hematoma, or the blood that has pooled, has spread. They can also detect other injuries related to the face like fractures in face bones, a ruptured eyeball, or foreign objects stuck inside the eye. CT images can further reveal if there’s tension (pressure or pulling) on the optic nerve or an abnormal curve at the back of the eye.
However, if a patient is showing signs that are typical of blood supply getting cut off to the optic nerve due to RBH, surgery should be the immediate priority. This condition requires urgent attention, so, in such cases, doctors delay getting imaging scans done in favour of quick surgical intervention.
Treatment Options for Retrobulbar Hematoma
If you have been diagnosed with a retrobulbar hematoma, which is a build-up of blood at the back of the eye, the doctor will need to act urgently. This condition is serious because it may harm the optic nerve that controls your vision by decreasing the blood flow to it, especially if the pressure inside your eye (intraocular pressure) is 40 mmHg or more. When this happens, medicines for pain relief and anti-vomiting will be administered to ensure comfort and avoid any increase in pressure due to acts like vomiting. One crucial step in management is immediate decompression of the orbit or the eye socket. This procedure involves creating an incision on the outer corner of the eye to release the built-up pressure, a process known as lateral orbital canthotomy and cantholysis or LOCC.
For this procedure, if possible, the area around the eye will be cleaned with a solution called povidone-iodine to ensure sterility, but saline can be used in emergencies. Anesthetic will be administered into the skin and deeper tissues around the outer corner of your eye to numb the area. Then the surgical field is cleaned with sterile water. A device known as a hemostat is then used to clamp the outside corner of the eye for about a minute. After this, the doctor will make a small cut in the outer corner of your eye.
From here, the doctor will work to expose a part of your eye called the lateral canthal tendon by cutting at it. Cutting this tendon is important because it helps to relieve the increased pressure by disconnecting the lower eyelid from the eye socket. However, the incision might have to be fixed later.
In minor cases where the optic nerve is not at risk, some patients just need to observed or treated with medication. Patients who don’t show symptoms or an increase in eye pressure can be looked after without any major intervention. Follow-ups will be required to monitor any potential changes. Less severe cases might be treated with medications (like beta-blockers, steroids, or osmotic agents) or even direct drainage of the hematoma. These treatments can help to decrease the pressure inside the eye. Other medications such as oral or intravenous Acetazolamide have been successful in lowering eye pressure, too. Steroids might also protect against trauma to the optic nerve. But no matter the treatment, it’s important to later follow up with an eye doctor.
In cases following surgery, preventing a retrobulbar hematoma is key. While specific risk factors are not well known, optimizing conditions before surgery can be helpful. For instance, patients who are on blood thinners at the time of their eye-related surgery might be at a higher risk for a retrobulbar hematoma. Therefore, it could be advisable for patients to stop taking agents like this before the operation, if possible. During the surgery, achieving adequate blood control and preventing activities that might cause changes in pressure could be beneficial.
What else can Retrobulbar Hematoma be?
When patients show the symptoms previously mentioned, especially following an injury, doctors must also think about two other conditions. These include a ruptured eye globe and fractures of the eye socket that can trap muscles or nerves.
What to expect with Retrobulbar Hematoma
Generally, people who get immediate medical attention when they have this condition will recover well. Those who get treatment within 2 hours of noticing the condition, often regain an eye vision better than 20/40. However, if treatment is received more than 2 hours after the condition starts, only 1 in 4 patients might achieve vision of 20/40 or better. There have been cases where individuals who faced severe injury like “No Light Perception” vision regained some sight after treatment.
However, certain factors can signal a poorer outlook, including having a starting vision worse than 20/200. This could also be the case if the patient has a weakened response of the pupil to light, if the eyelid is lacerated, or if treatment was delayed. Another factor negatively impacting recovery is when the hematoma or swelling, behind the eye is caused by an accident and there are a large number of symptoms.
On a serious note, in cases of injury causing sudden loss of vision due to hemorrhage or severe bleeding behind the eye, the risk of permanent vision loss is between 44% to 52%. That being said, if this type of intense bleeding happens as a result of surgery, the chances of permanent vision loss significantly drops.
Possible Complications When Diagnosed with Retrobulbar Hematoma
After a LOCC procedure, it’s normal to have a consistent increase in eye pressure, suggesting that the cantholysis, a part of the procedure, may not have been sufficient. In such cases, it’s important to ensure that a good lower cantholysis was performed. If necessary, an additional cantholysis might have to be performed on the upper part of the lateral canthal tendon to alleviate the pressure on the orbit.
There could also be other problems due to the procedure. These may include damage to nearby parts of the eye, ruptured eyeball, infection, bleeding, or the eyelid being in an incorrect position. There might also be a drooping lower eyelid, which could lead to aesthetic concerns. These can be fixed at a later stage by ophthalmologists who are experts in oculoplastic surgery, once the immediate risk of losing vision has abated.
- Persistent increase in eye pressure
- Damage to nearby ocular structures
- Ruptured eyeball
- Infection and bleeding
- Eyelid malpositioning
- Drooping lower eyelid
Recovery from Retrobulbar Hematoma
Once a LOCC, or a type of eye surgery, is fully performed, a couple of things need to be rechecked. These include the patient’s visual acuity or sharpness of vision, IOP (intraocular pressure which is the fluid pressure inside the eye), how the patient’s pupils are functioning, and any other signs that the optic nerve (the nerve that connects the eye to the brain) may not be getting enough blood supply. Depending on the findings, the patient may need additional treatments like eye drops to lower their IOP or other systemic agents which are drugs that work throughout the body.
The surgery site should also be regularly monitored for any signs of infection. As a precaution, topical ophthalmic antibiotic ointment, such as erythromycin and bacitracin, should be applied to the surgery site. This is a special type of medication that is applied directly to the skin at the site of the surgery to prevent infection.
Preventing Retrobulbar Hematoma
It’s essential for patients to understand the significance of prevention and eye safety. Wearing the right eye protection, especially in areas where the risk of eye injury is high such as construction sites, sports arenas or the military, is crucial. In certain situations, it’s recommended to use helmets, face shields, and safety goggles. Protection for the eyes is particularly important for individuals who can only see out of one eye.