Abstract
Retrobulbar haematoma is a rare emergency that can potentially lead to blindness. Common causes include facial trauma and surgery. Timely surgical evacuation of the haematoma improves visual outcomes. In rural communities, patients often present to hospital after many hours and this increases the risk of poor visual outcomes. Radiological evaluation which is often not available in rural communities, results in further delay in surgical treatment. This case report highlights the need for urgent surgical intervention over radiological evaluation in patients with retrobulbar haematoma and orbital compartment syndrome.
Keywords
Introduction
Retrobulbar haematoma (RBH) is rare, but potentially threatens sight. Common causes are trauma to the face and surgery. Other rare causes include Valsalva manoeuvres, anticoagulation therapy and vascular abnormalities. 1
The reported incidence of RBH following trauma to the head ranges from 0.35% to 4%. 2 The bleeding can be venous or arterial. RBH can potentially lead to visual loss as a result of orbital compartment syndrome. In a systematic review of 93 cases requiring emergency surgical evacuation, 51% had complete visual recovery, 27% had partial recovery, and 22% developed blindness. 3
The pathophysiological events that lead to blindness include an increase in intraorbital pressure, stretching of the optic nerve, compression of optic veins, central retinal artery occlusion and ischaemic optic neuropathy. 4 RBH also causes anterior displacement of the globe which results in corneal oedema, ulceration and scarring. Increased time to surgical evacuation of RBH is associated with worse visual outcome. 5
Case presentation
A 17-year-old male presented to our emergency department with a complaint of gross right eye protrusion and reduced vision in the affected eye. He reported stumbling into a wall while walking at night to go to the latrine four days prior to coming to hospital. Initially dismissing the injury as trivial, he did not seek any medical care until he noticed severe eye protrusion and poor vision in the affected eye.
On examination, he had marked right eye proptosis, chemosis, and restricted extraocular movements. He was also unable to close the eyelids on the affected side (Fig. 1). His visual acuity in the affected eye had deteriorated to light perception. There was significant corneal and conjunctival oedema, as well as a corneal ulcer. A computed tomography scan confirmed the RBH (Fig. 2). Approximately 20 ml of blood was drained through a sub-brow (Benedict) incision under general anaesthesia resulting in immediate retraction of the eyeball into the orbit. A tube drain was placed in the retrobulbar space (Fig. 3). An eye pad was applied post-operatively. After 72 h, the conjunctival and corneal oedema had resolved with marked improvement in visual acuity.
Severe proptosis, chemosis and corneal ulceration; preoperative.
Computed tomography scan radiograph showing a retrobulbar hematoma with anterior displacement of the right eyeball.
Retraction of eyeball back into the orbit and retrobulbar tube drain; immediate post-operative.
The corneal ulcer in periphery of the cornea showed signs of healing with minimal scarring. Follow-up after 14 days revealed no residual ocular deficit. There was minimal corneal scarring in the inferior margin of the cornea which was not interfering with vision (Fig. 4).
Fourteenth post-operative day with a clear lustrous corneal and minimal corneal scar in the medial and inferior margins.
Discussion
By 96 h after his injury, our patient had developed severe corneal oedema, a corneal ulcer and minimal visual acuity. Radiological imaging and the need for general anaesthesia, which are often not available in low-resource communities as our own, will result in unnecessary and potentially damaging further delay, particularly in patients with features of optic nerve ischaemia. 5 Ultrasound scan, if available can easily and accurately diagnose RBH. 6
Emergency lateral canthotomy under local anaesthesia is a safe procedure to relieve tension in the orbit.7,8
This case underscores the need for clinicians in low-resource health facilities to be able to perform simple emergency procedures under local anaesthesia or ketamine.
Footnotes
Acknowledgements
The authors acknowledge the support of Ms Nakiyaga Gertrude for providing safe anaesthesia and post-operative care for this patient.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Informed consent
The authors obtained informed written consent from the mother of the teenage boy to report this case for academic and learning purposes and also to take and use photographs of the patient for this case report.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
