First description of a retrobulbar haemorrhage in a paediatric patient

Abstract

An 8-year-old girl presented to the paediatric emergency department 3 days after left orbital exploration for an orbital floor fracture. She had been vomiting for the last 24 hours and her mother’s primary reason for presentation was that she was unable to keep down any analgesia. She reported pain in that eye and was unable to see. On examination, the eye was swollen and had yellow discharge. A CT scan was performed to rule out an infective collection and, unexpectedly, showed a retrobulbar haematoma. Ophthalmology was called and she was immediately taken to theatre for a lateral canthotomy for decompression. Fortunately, she regained her vision following this but, had the retrobulbar haematoma not been recognised urgently, she may have lost her vision permanently in that eye. Retrobulbar haematomas are quite rare in children this age and there is very little published literature on this topic.

Background

Retrobulbar haemorrhages (RBHs) are a serious complication following any type of orbital trauma and may cause orbit compartment syndrome (OCS). OCS occurs when there is a rapid increase in intraorbital pressure, which in turn reduces blood flow to the retina and optic nerve. The incidence of RBH following an orbit trauma is less than 1% in the adult population.¹ There is minimal literature available currently on RBH in the paediatric population. The rarity of this condition makes it easy for clinicians to miss and may delay diagnosis. A lag in diagnosing OCS confers a high risk of ischaemia and, consequently, blindness due to retinal infarction.

Case presentation

An 8-year-old girl presented to paediatric emergency department (PED) at midnight, with ongoing vomiting 3 days after left orbital surgery. Two months prior to this admission, she had tripped over and hit her head on a wooden bench, leading to a left orbital floor fracture and trapping of the inferior rectus secondary to the trauma. Eye examination showed restriction of the left eye in upward gaze. A left orbital floor fracture repair with titanium implant was performed. The patient continued to have significant restriction of elevation with diplopia. Review of CT of her orbits showed the prosthesis in situ, but continued herniation of tissue into the left maxillary sinus. The patient underwent a second left orbital exploration and implant. With residual diplopia and restriction on upward gaze.

Following this second procedure, 3 days later, the patient presented with persistent vomiting, painful left eye with swelling to the PED. Parental concern was mostly over the vomiting, as she was not able to tolerate analgesia.

The left eyelid was visibly swollen, with some yellow discharge and significant pain, making examination difficult. The eyelid was unable to be opened. The patient was afebrile with normal observations. The patient was very scared and anxious following the procedure earlier on the week and required encouragement for any investigations to be done. Given the level of pain, the vomiting and the discharge from the left eye a working diagnosis of a postoperative complication was considered, but also gastroenteritis. At the time, RBH was not considered, but infection was, given the yellow discharge.

Investigations

A CT scan (figure 1) was performed. It revealed a 3 cm retrobulbar haematoma causing mass effect with distortion of the posterior globe and an approximately 8 mm unilateral proptosis.

Figure 1.

CT scan showing a retrobulbar haemorrhage of 3 cm behind the left eye.

Differential diagnosis

Given that the parental primary concern was that of vomiting, the preliminary differential diagnosis to consider was gastroenteritis. However, the associated eye symptoms made this an unlikely diagnosis and it was soon ruled out.

We contemplated an intracranial pathology as a rise in the intracranial pressure could have led to her symptoms of vomiting and pain. Her other symptoms did not correlate with this diagnosis.

Due to the swelling surrounding the eye and the yellow discharge, we considered a potential infective cause. Bloods were taken to check for raised inflammatory markers. While awaiting the results, we considered the possibility of an infective collection leading to visible proptosis. This led us to performing a CT scan (figure 1), which in turn confirmed an retrobulbar haematoma.

Treatment

Concurrently, we prepared for the possibility of performing a lateral canthotomy in PED.² This is a painful procedure that involves cutting through the lateral canthal ligament. This relieves raised intraocular pressure by allowing the orbital contents to move forward. Even in an adult patient, the decision to perform this procedure urgently in the emergency department is a challenging one. In a child, we had several additional factors to consider, such as lack of compliance from the patient as well as parental anxiety. An option would be to consider sedation for this procedure, such as with ketamine. Ketamine sedations in the PED are common for procedures such as fracture manipulation and wound management.³ However, given these symptoms had been going on for 3 days, the ophthalmology team were keen to explore this in the operating theatre. Within 1 hour of the CT report, the patient was in the operating theatre for her definitive treatment.

Outcome and follow-up

Postoperative CT confirmed that the entire haematoma was removed. Eleven days later at a clinic appointment, the canthotomy scar was found to be healing well. The patient’s affected left eye had visual acuity of 6/6 vs 6/4 in the unaffected right eye. She retained normal colour vision, though continued to have diplopia in upgaze. Four months postoperatively, she was discharged from clinic follow-ups. Her fracture and repair has healed well and she has no interference with her regular activities.

Discussion

The orbit is an enclosed space with bony walls on all sides, apart from anteriorly. Any accumulation of fluid within the orbit can lead to a rapid increase in intraorbital pressure and, subsequently, OCS. OCS is a sight-threatening ophthalmic emergency requiring prompt intervention to prevent blindness. Retrobulbar haematomas are a documented, although uncommon, occurrence following orbital surgery. The consensus for the adult population is that a clinical suspicion of OCS requires immediate decompression with a lateral canthotomy, without the need for diagnostic imaging. However, there is very limited guidance available regarding this topic in the paediatric population.

Patient’s perspective.

My initial thoughts, when bringing my daughter to A&E (Accident and Emergency/ Paediatric Emergency Department) that night, 3 days after planned surgery with vomiting, was a post-operative infection as the eye was swelling and there was increased pain. On reflection, her eye had swollen a lot more than I had realised in a short space of time. Despite being aware of the rare complications from surgery, you never think that it is you that has that 1% chance of a bleed post-operatively, let alone several days after the planned surgery.

As a parent, I am just so thankful that the fantastic doctor on shift that night organised an urgent head CT scan with contrast that highlighted the bleed so quickly and ultimately saved my daughters eyesight. The vomiting could have quite easily been put down to the anaesthetic or gastroenteritis and we could have been sent home.

I am so pleased that the experience is being shared among other healthcare professionals so that the awareness of rare complications can be highlighted and learnt from which may benefit other patients in the future.

Learning points.

• Despite the rarity of retrobulbar haematomas in children, it is crucial to keep it in mind when examining a child with visual disturbances following orbit trauma or surgery.

• Recognising the various signs of raised intraorbital pressure, including vomiting and proptosis, is paramount.

• Immediate decompression must be performed if orbit compartment syndrome is suspected.

Ethics statements

Patient consent for publication

Parental/guardian consent obtained.