Postoperative Complication from Eyelid Surgery

Paul A. Brannan and David B. Hom

History

The patient is a 55-year-old man who has just undergone bilateral lower lid blepharoplasty. He suffered a severe coughing episode in the recovery area and experienced sudden pain behind both eyes. He complained of double vision and difficulty seeing. When questioned about his medications, he admitted that he had not taken his antihypertensive this morning and had taken multiple aspirin tablets for a headache over the past few days.

Examination revealed a man in moderate distress, blood pressure 180/95, with a pulse of 115. He had diffuse periorbital ecchymoses and gross proptosis. Motility was limited in all directions, and he was able to count fingers with both eyes.

Differential Diagnosis—Key Points

1. This is a vision-threatening emergency that needs to be addressed quickly to avoid loss of vision.

2. Orbital hemorrhage is the most likely diagnosis given the history of recent eyelid surgery, ecchymosis, decreased vision, pain, and proptosis. An acute glaucoma attack would cause pain and decreased vision but would not manifest with ecchymosis or proptosis. A corneal abrasion would also cause pain and blurry vision only. Retinal detachment is unlikely and would result only in diminished vision.

3. The intraocular eye pressure and a funduscopic examination of the retinal veins and arteries should also be checked if possible. These require specialized equipment and an ophthalmologist to perform them correctly; however, the urgency of the situation may not allow for this.

Test Interpretation

No specific test should be performed in this urgent situation other than ophthalmic consultation.

Diagnosis

Postoperative orbital hemorrhage with an orbital hematoma

Management of an orbital hemorrhage requires a correct, timely diagnosis and a complete understanding of the process. Intraocular pressure is elevated when a significant hematoma is present. However, this pressure increase is directly related to orbital pressure and is not a problem intrinsic to the eyeball. Management of this problem should not be directed at lowering the eye pressure with topical or systemic medications. The goal is to lower intraorbital pressure by increasing orbital volume. This can be accomplished by several surgical methods.

In the presence of a post-blepharoplasty patient with an orbital hemorrhage, the following steps are recommended:

1. Call for immediate ophthalmic consultation.

2.