T 98.7 HR 68 RR 22 BP 220/65 SpO2 95% on RA

General: Elderly female with significant trauma to her right eye, face, lip, and bloody clothing. Awake, alert, appropriate, conversational.

HEENT: Patient with significant facial trauma: Right eye swollen shut, with significant surrounding ecchymoses and swelling over right maxilla. Right eye is proptotic, with significant chemosis, fixed mid dilated pupil not reactive to light, patient able to tell light vs. dark but cannot see movement. Patient able to move eye only very slightly. Left eye atraumatic with round and reactive pupil and full extraocular motions. Right maxilla with overlying swelling, no pain on palpation of the face, no battle sign

Neck: supple, trachea midline, no C-spine tenderness

Pulmonary: CTA b/l, no chest wall tenderness

Cardiac: RRR no MRG

Abdomen: soft, NTND, no bruising or signs of trauma, pelvis stable

Musculoskeletal: Atraumaic exam except as described above

Neuro: GCS 15, AAOx4, cranial nerves II - XII grossly intact except for R eye exam as documented above, symmetric face, gait exam deferred secondary to chief complaint; strength 5/5 in all four extremities; sensation grossly intact

Hospital Course

The patient presented one hour after facial trauma with a proptotic right eye, only light/dark differentiation in that eye, as well as loss of extra-ocular movements and an afferent pupillary defect. Together, these findings were classic for retrobulbar hematoma. This was corroborated on her maxillofacial CT. Due to the patient’s significant vision deficits on presentation, a right lateral canthotomy with cantholysis was performed urgently at bedside, with successful release of the upper and lower canthal ligaments. After the procedure, the patient had no improvement in her vision, and worsened from light/dark perception to complete vision loss. Her IOPs remained persistently elevated in above 80 mm Hg. Her IOP was acutely managed with timolol drops as well as mannitol, with some improvement in her IOPs. She was admitted for a syncope workup, management of her ophthalmologic issues , and multiple orbital and mid-face fractures. The patient ultimately suffered complete vision loss in her right eye.

Management of Retrobulbar Hematomas

Retrobulbar hematoma, which can also be conceptualized as “orbital compartment syndrome,” is a vision-threatening condition and ophthalmologic emergency. Retrobulbar hemorrhage has been described after trauma as well as after facial surgery, and this presentation may be delayed up to days after injury. [2] This is an uncommon condition, even in the setting of orbital fracture – only 0.45-0.6% of patients with orbital fracture have a coexisting retrobulbar hematoma. However, it is quite morbid, as patients who present with vision loss in the setting of retrobulbar hemorrhage have a 44-52% chance of permanent blindness. The retina may tolerate approximately two hours of ischemia before vision loss is irreversible. [1]