BASICS

DESCRIPTION

An orbital hemorrhage is a hemorrhage within the orbital cavity, bound anteriorly by the orbital septum and canthal tendons.

EPIDEMIOLOGY

Incidence

• Orbital fractures (0.45–0.6%)

• Retrobulbar injections (0.005–0.44%)

• Facial fracture repair (0.24–0.3%)

• Postblepharoplasty (0.005%)

• Endoscopic sinus surgery (0.43%)

RISK FACTORS

• Blunt head/orbital trauma

• Penetrating orbital foreign bodies

• Postseptal eyelid surgery

• Orbital/sinus surgery

• Hypertension

• Anticoagulant medications (aspirin, NSAIDs, warfarin [Coumadin])

• Postoperative Valsalva maneuver (vomit, cough, sneeze)

• Coagulopathy

• Blood dyscrasia (thrombocytopenia, leukemia)

• Cirrhosis

GENERAL PREVENTION

• Preoperative assessment of risk factors

• Meticulous intraoperative hemostasis

• Postoperative patient education and surveillance

PATHOPHYSIOLOGY

• An orbital hemorrhage acts like an expanding space occupying orbital lesion confined by the bony orbital walls and orbital septum.

• As the intraorbital pressure increases, the eye and orbital contents bulge anteriorly to the limit of the orbital septum and canthal tendons (7–8 mm). Beyond that, the optic nerve is maximally stretched, limiting further anterior displacement of the globe.

• Subsequent increases in orbital pressure can produce visual loss by direct optic nerve compression, or more likely, by ischemic optic neuropathy from compression of the central retinal artery, posterior ciliary vessels, and fine pial perforating vessels supplying the retina, choroid, and optic nerve.

ETIOLOGY

• Blunt and penetrating orbital trauma

• Eyelid, orbital, sinus, and lacrimal surgery

• Idiopathic (rare)

COMMONLY ASSOCIATED CONDITIONS

Spontaneous orbital hemorrhage has occurred with

• Orbital lymphangiomas

• Cavernous hemangiomas

• Ophthalmic artery aneurysms

• Hemophilia

• Leukemia

• Vitamin K deficiency

• Anemia

• Hypertension

• Von Willebrand’s disease

DIAGNOSIS

HISTORY

• Recent trauma to the eye, orbit

• Recent eyelid, lacrimal, orbital, or sinus surgery

• Sudden ocular and orbital pain

• Diplopia

• Nausea/vomiting

PHYSICAL EXAM

Complete ophthalmic exam checking for

• Decreased visual acuity

• Afferent papillary defect

• Limited extraocular motility

• Loss of color vision

• Eyelid ecchymosis

• Progressive proptosis with resistance to retropulsion

• Chemosis

• Diffuse subconjunctival hemorrhage

• Elevated intraocular pressure (IOP)

• Optic disc and retinal pallor

• Central artery pulsations

• Choroidal folds

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

• CBC & differential

• PT, PTT, platelets

Follow-up & special considerations

Hematology/oncology evaluation if blood dyscrasia

Imaging

Initial approach

• Orbital CT scan (axial and coronal views)

• If vision is threatened, CT scan should be delayed until initial treatment has been instituted (see below).

Diagnostic Procedures/Other

• In spontaneous orbital hemorrhage, consider MRI (using head coils) if suspect vascular malformation or mass.

– Biopsy of mass if present with spontaneous orbital hemorrhage

Pathological Findings

If spontaneous orbital hemorrhage, biopsy of mass may show vascular anomaly including

• Orbital lymphangiomas

• Cavernous hemangiomas

DIFFERENTIAL DIAGNOSIS

• Orbital cellulitis

• Orbital fractures (floor, medial wall, tripod)

• Ruptured globe

• Subperiosteal hemorrhage

• Optic nerve sheath hemorrhage

TREATMENT

MEDICATION

• Hyperosmotic agent (mannitol 20% 1–2 g/kg IV over 45 minutes)

– Acetazolamide 500 mg IV

– Methylprednisolone 100 mg IV for neuroprotection

– Topical beta-blocker (timolol ½% q30min × 2)

ADDITIONAL TREATMENT

General Measures

If vision is threatened, then a lateral canthotomy and cantholysis of the inferior and superior lateral canthal tendons should be done at the same time that medical therapy is being instituted and before the patient is sent for the CT scan.

Issues for Referral

• Hematology/oncology, if blood dyscrasia, if spontaneous retrobulbar hemorrhage

– ENT, if postoperative sinus surgery

Additional Therapies

• Treat underlying blood dyscrasia, if spontaneous orbital hemorrhage

• Orbital exploration to find and ligate bleeder, if patient is postoperative orbital, sinus, lacrimal, or eyelid surgery

• Drain subperiosteal hemorrhage, if present.

SURGERY/OTHER PROCEDURES

• Optic nerve sheath decompression if optic nerve sheath hemorrhage

• Two wall (floor and medial wall) decompressions if the above measures fail.

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Airway, respiration, and circulation (ABCs), in acute trauma

Admission Criteria

• Progressive visual loss

• For IV pulse therapy with corticosteroids

IV Fluids

Methylprednisolone 250 mg q6h for 12 doses

Nursing

Frequent vision checks

Discharge Criteria

Stable vision

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• See patient education

• Hematology/oncology consultation. If spontaneous orbital hemorrhage

Patient Monitoring

For postoperative visual acuities, IOP, motility, pupils, color vision, and external evaluation for proptosis

DIET

Preoperative and postoperative diet: low in garlic ginger, ginseng, ginkgo, high in antioxidants

PATIENT EDUCATION

• Preoperatively, patients should discontinue vitamin E, anticoagulants, antiplatelet agents, and herbal supplements, if medically stable (preinternist). compresses

– Postoperatively, patients should apply ice. Avoid Valsalva maneuvers (bending, lifting, coughing, sneezing, nose blowing, straining at stool).

– Seek medical attention stat, if sudden loss of vision, explosive exophthalmos, or severe orbital pain.

PROGNOSIS

• Poor, if visual loss is beyond 100 minutes of acute bleed

• Fair, if above treatment is instituted within 100 minutes of acute bleed

COMPLICATIONS

Loss of vision

ADDITIONAL READING

• Lelli GJ, Lisman RD. Blepharoplasty complications. Plast Reconstr Surg 2010;125(3):1007–1017.

• Lewis CD, Perry JD. Retrobulbar hemorrhage: epidemiology/incidence. Expert Rev Ophthalmol 2007;2(04):557–570.

• Sullivan TJ, Wright JE. Non-traumatic orbital hemorrhage. Clin Experiment Ophthalmol 2000;28(1):26–31.

• Tan JC, Chan EW, Looi A. Bilateral orbital subperiosteal hemorrhage following labor. Ophthal Plastic Reconstr Surg 2011;27(3):e59–e63.

CODES

ICD9

• 376.32 Orbital hemorrhage

• 377.42 Optic nerve sheath hemorrhage

• 871.0 Ocular laceration without prolapse of intraocular tissue

CLINICAL PEARLS

• Most orbital hemorrhages are from trauma or are postoperative lid, orbit, sinus, or lacrimal surgery.

• Prevention depends on careful preoperative, intraoperative, and postoperative management.

• Emergent surgical intervention (lateral canthotomy/cantholysis and wound exploration if necessary) are the definitive treatment.

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