Summary:
Retrobulbar hemorrhage can increase intraorbital pressure, thereby elevating intraocular pressure (IOP), inducing ischemia, and/or threatening the optic nerve. Emergent decompression is needed to preserve visual function. Multiple decompression methods that are favored by different clinical departments have been reported. Here, we report 2 emergency room cases of retrobulbar hemorrhage that were treated first with lateral canthotomy and inferior cantholysis (LC/IC) under local anesthesia followed an hour later by wide orbital septum release under general anesthesia. LC/IC permits the quickest possible decompression after injury, thus temporarily reducing IOP. Orbital septum release consolidates the decompression by permitting hematoma drainage and identification and hemostasis of the bleeding point. In our cases, IOP dropped from 55 and 52 mm Hg to 14 mm Hg in both cases, and corrected visual acuity improved from light perception/counting fingers to 20/20. Notably, LC/IC was only conducted 7 and 4 hours postinjury. This counters the commonly held view that decompression should occur within 2 hours of injury to achieve visual recovery. Thus, even though LC/IC followed by orbital septum release requires 2 surgical steps, it can result in excellent visual outcomes after retrobulbar hemorrhage.
Retrobulbar hemorrhage is one of the most common oculoplastic emergencies. It can increase intraorbital pressure, thereby inducing optic nerve damage/ischemia and raising intraocular pressure (IOP). Because it is associated with high rates of blindness (44%–52%), it is crucial to decompress the eye, ideally within 2 hours of symptom onset.1 This generally involves surgically releasing the pressurized part of the orbital compartment. A common method is lateral canthotomy (LC) and inferior cantholysis (IC). However, there are reports that it may not decompress the orbit sufficiently.2,3 Here, we report 2 cases where LC/IC was conducted under local anesthesia to temporarily reduce intraorbital pressure, after which orbital septum release was performed under general anesthesia. This safely and effectively preserved visual function.
CASE PRESENTATION
Case 1
A 92-year-old man taking antiplatelet drugs was brought to the emergency room after his wife found him collapsed at home with the sudden loss of vision in his right eye. The right eye had light perception only, proptosis, and lacked direct and indirect light reflexes. Right-eye IOP was 55 mm Hg. Computed tomography (CT) revealed a fracture in the outer wall of the right orbit, hematoma, and protrusion of the eyeball due to increased IOP from retrobulbar hemorrhage (Fig. 1). Seven hours postinjury, LC/IC was performed under local anesthesia. An hour later, the inferior orbital septum was incised under general anesthesia. This permitted access to the orbital floor and removal of the hematoma. Hemorrhage was stopped by identifying a hemorrhage point within the outer orbital fat. This improved the proptosis. A drain was placed at the infraorbital to the external eye angle wound, and the surgery was ended. The next day, IOP improved to 14 mm Hg, corrected visual acuity recovered to 20/20, and the light reflex normalized. The drain was removed the day after surgery. As blood loss was low, antiplatelet drugs were resumed the day after surgery. CT also confirmed normalization. (See figure, Supplemental Digital Content 1, which displays case 1: CT 2 weeks postoperatively. Improvement of the ocular protrusion and hematoma is noted, http://links.lww.com/PRSGO/D889.)
Fig. 1.
Case 1. CT revealed a hematoma in the right orbit and protrusion of the eyeball.
Case 2
A 72-year-old woman fell at home and hit her right eye. She was brought to the emergency room with right vision loss and eye pain. The right eye could count fingers and exhibited proptosis. The light reflex was normal. IOP was 52 mm Hg. CT revealed a fracture of the right orbital floor, hematoma, and protrusion of the eyeball due to increased IOP from retrobulbar hemorrhage. Four hours postinjury, LC/IC was performed under local anesthesia. An hour later, the inferior orbital septum was incised under general anesthesia. This permitted access to the orbital floor and removal of the hematoma. Hemorrhage was stopped by identifying a hemorrhage point within the orbital fracture site. A drain was placed at the infraorbital to the external eye angle wound, and the surgery was ended. Immediately after the operation, IOP improved to 23 mm Hg. The next day, IOP improved to 14 mm Hg, and corrected visual acuity recovered to 20/20. The drain was removed 3 days after surgery.
DISCUSSION
The front of the orbit is covered by the superior and inferior orbital diaphragms, whereas its sides, back, and bottom are bounded by the bones, periosteum, and muscles that make up the orbit. Normal IOP is 10–20 mm Hg. Retrobulbar hemorrhage refers to bleeding within a closed space in the orbit. This can increase IOP, induce ischemia, and/or impact the optic nerve, thus inducing blindness.4 It should be noted that even when the orbital compartment appears to be open due to fracture, persistent bleeding can still increase the IOP. This was observed in case 2, in which the orbital floor was fractured. Caution is required in such cases.2,5
Decompression is indicated in cases of retrobulbar hemorrhage, as well as the following clinical signs: increased IOP of 30 mm Hg or more, sudden visual-acuity loss, pupillary abnormalities (eg, light reflex loss or abnormal pupil enlargement), restricted eye movement, or abnormal eye proptosis.6 Surgical decompressive approaches include LC/IC, the pterional-orbital approach, the transcranial approach, and orbital septum release7,8 (Table 1). This variety of decompression procedures reflects the fact that the physicians who diagnose and treat retrobulbar hemorrhage range from critical care physicians to plastic surgeons, ophthalmologists, and maxillofacial surgeons. In recent years, LC/IC has become the gold standard for the surgical treatment of retrobulbar hemorrhage because it immediately decreases IOP.9 However, older reports suggest that LC/IC alone may not provide sufficient decompression, and additional decompression surgery is required.2,3
Table 1.
Advantages and Disadvantages of the Techniques Used to Decompress Elevated IOP Due to Retrobulbar Hemorrhage
| Approach | Advantages | Disadvantages | Suitability for Emergent Cases | Can Be Performed by Medical Department |
|---|---|---|---|---|
| LC/IC(C) | • Can be performed under local anesthesia • Rapid decompression • Simple techniques |
• Decompression is temporary • Cannot remove hematoma and identify bleeding • Ectropion of lower eyelid |
• Suitable for emergency decompression | • Emergency surgery • Ophthalmology • Maxillofacial surgery • Plastic surgery |
| Orbital septum release | • Can be performed under local anesthesia • Provides a wide field of vision that permits hematoma removal and bleeding point identification |
• Ectropion of lower eyelid • Wound scarring |
• Suitable for emergency decompression | • Ophthalmology • Maxillofacial surgery • Plastic surgery |
| Transcranial approach | • Wounds in hair part • Can be used for diffuse hemorrhage • Can decompress the optic canal |
• Risk of nerve damage and infection • Requires proficiency |
• Takes time to induce decompression |
• Neurological surgery |
| Pterional-orbital approach | • Wounds in hair part • Can be used for diffuse hemorrhage • Can decompress the optic canal |
• Risk of nerve damage and infection • Requires proficiency |
• Takes time to induce decompression | • Neurological surgery |
C, cantholysis.
In our cases, LC/IC was conducted under local anesthesia, after which the orbital septum was released under general anesthesia to remove the hematoma and stop the bleeding (Fig. 2). In both cases, the orbital septum was opened through a subciliary incision. The incision line should be just enough to ensure that the orbit is sufficiently open and the field of vision is adequate.
Fig. 2.
Schema for emergency LC followed by orbital septum release. LC/IC was performed under local anesthesia (1) and inferior orbital septum incision was performed under general anesthesia (2). Intraoperative eye protection was provided by suturing the lower eyelid margin and upper eyelid. The incision layers are the skin, orbicularis oculi muscle and orbital septum in the case of a subciliary incision, and the conjunctiva and orbital septum in the case of a conjunctival incision to open up the inferior margin of the orbit. The addition of an orbital septum incision allows removal of the hematoma and confirmation of the bleeding point under direct visualization.
We obtained excellent outcomes: the IOP normalized quickly, and vision in both cases improved from light perception/counting fingers to 20/20 corrected visual acuity. Our approach is supported by Oester et al,10 who found that combining LC/IC with inferior orbital septum release synergistically reduces IOP, regardless of the order. The good outcomes of this combined approach reflect the fact that LC/IC achieves rapid decompression, but only orbital septum release, which provides a wide field of view, permits complete hematoma removal and bleeding point identification. This combined approach is likely to be particularly advantageous for traumatic retrobulbar hemorrhage, where the bleeding often originates from the fracture site and can only be identified by accessing the orbital floor. Alternatives to LC/IC and orbital septum release, namely, transcranial and pterional techniques, are less suitable for emergent cases because they are more complex than orbital septum release and provide decompression more slowly (Table 1). Notably, infraorbital skin incisions are commonly conducted in plastic surgery to treat facial bone fractures: thus, inferior orbital septum release is a feasible technique for younger surgeons. These findings indicate that adding orbital septum release to the standard LC/IC procedure can yield good improved outcomes, even though it involves 2 separate procedures.
It should be noted that LC/IC in our cases was conducted 7 and 4 hours postinjury. It is widely thought that decompression surgery may not improve visual acuity if it is performed more than 2 hours postinjury. However, our cases suggest that it is worth performing surgery even if the postinjury duration exceeds 2 hours. Some believe that if posttraumatic vision loss progresses slowly, there is also a high likelihood of good recovery of vision.4 This notion is supported by cases in the literature where visual acuity was fully restored by decompression up to 7 hours postinjury (Table 2).1–3,5,7,8
Table 2.
Cases in the Literature Where Decompression Was Performed More Than 2 Hours After Injury
| Author (Year) | Sex | Age, y | Preinjury Medications | Etiology | Delay, h | Treatment | Final VA |
|---|---|---|---|---|---|---|---|
| Amagasaki (1998)7 | M | 17 | — | Sports trauma | 6 | Transcranial | 20/40 |
| Popat (2007)8 | F | 77 | — | Fall | 5 | LC, C* | NLP |
| Colleti (2012)2 | F | 36 | — | Accidental trauma | 12 | LC, IC, transconjunctival lower eyelid approach | NLP |
| Maurer (2013)5 | F | 88 | Phenprocoumon | N/A | 2.5 | Inferior orbital septum release with infraorbital skin incision | Impaired |
| F | 80 | Acetylsalicylic acid | N/A | 2.5 | Inferior orbital septum release with infraorbital skin incision | Impaired | |
| Sum (2014)1 | M | 56 | — | Workplace accident: crank arm to face | 2.5 | LC, IC | 20/125 |
| M | 41 | — | Physical assault: fist to face | 3.5 | LC, IC, release of lateral one-third of inferior orbital septum | HM | |
| F | 83 | — | Fall: floor to face | 7 | LC, IC | HM | |
| Voss (2016)3 | F | 64 | — | Fall | 6.5 | LC, C* | NLP |
| Ochi (current study) | M | 92 | Antiplatelet drugs | Fall | 7 | LC, IC, inferior orbital septum release | 20/20 |
| F | 72 | Fall | 5 | LC, IC, inferior orbital septum release | 20/20 |
No indication of superior or inferior or both.
C, cantholysis; HM, hand motion; N/A, not available; NLP, no light perception; VA, visual acuity.
CONCLUSIONS
Retrobulbar hemorrhage can induce blindness. Our cases show that adding orbital septum release to LC/IC can provide reliable decompression and visual recovery, even when LC/IC is conducted 7 hours postinjury.
DISCLOSURE
The authors have no financial interest to declare in relation to the content of this article.
Supplementary Material
Footnotes
Published online 3 March 2025.
Disclosure statements are at the end of this article, following the correspondence information.
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