Purpose: Retrobulbar hematoma (RH), a diagnostic and therapeutic emergency, is a serious complication of facial trauma that may cause permanent vision loss. Lateral canthotomy and cantholysis (LCC) is typically performed in cases of RH with elevated IOP or compromised vision. Existing literature on the presentation and treatment outcomes of RH is based on small case-series. We describe the outcomes of the largest cohort of patients with RH to date.
Methods: Patients who presented with acute facial trauma and RH to the R Adams Cowley Shock Trauma Center between 2014 and 2022 were analyzed to describe their presentation, management, and visual outcomes. Descriptive statistics and multivariate logistic and linear regressions were performed.
Results: A total of 41 eyes (39 patients) with RH were analyzed. The majority were males (31 [76%]) who presented following assault (20 [50%]). The most common presenting symptoms were orbital pain (19 [46%]) and diplopia (13 [32%]). The most common signs on ocular examination were subconjunctival hemorrhage (33 [81%]), proptosis (32 [78%]), and elevated IOP (20 of 38 measured were > 21 mm Hg [53%]). In our series, half the RH cases were managed with LCC (n=20), and the other half were observed (n=21). The median (IQR) IOP was significantly higher in the LCC group versus observation: 33 mm Hg (26-44) vs 18 mm Hg (15-21) (P=0.001). Compared to the observation group, patients treated by LCC were significantly more likely to have no light perception (NLP) vision (0 [0%] vs 6 [50%], P=0.004) and higher intraocular pressure (median [IQR] 16 mm Hg [15-21] vs 33 mm Hg [23-44], P=0.001) at presentation. All patients who had NLP at presentation (n=6) were managed by LCC. Of 17 patients who had reported IOP before LCC, 14 (82%) had lower IOP after LCC. In the 3 NLP patients where IOP did not drop, IOP was normal prior to LCC. Although one of the 6 NLP patients regained some vision after LCC, LCC was not associated with significantly different odds of improvement in visual acuity compared with observation (aOR [95% CI] 0.32 [0.04-2.98]). Visual acuity at presentation was the only significant predictor of visual acuity after follow-up (B=0.64, P=0.016).
Conclusion: Patients with RH typically present with proptosis, subconjunctival hemorrhage, and elevated IOP. LCC is indicated in cases of elevated IOP and results in a reduction of IOP, which helps with intraocular perfusion. Initial visual acuity at presentation is the most reliable predictor of long-term visual acuity outcome whether or not LCC is performed.