Surgical Treatment of Retrobulbar Hematoma

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To the Editor: Vision loss after facial trauma was related to injury of the globe, optic nerve damage, and retrobulbar hemorrhage (RBH).1,2 The RBH consists in bleeding of the posterior and anterior ethmoid arteries and orbital branch of the infraorbital artery leading to the increase of intraorbital pressure.3,4 This situation causes a decrease in blood perfusion in these regions, which can draw in a frame of ischemic optic nerve neuropathy or compression of the central retinal artery, resulting in vision loss.5 This paper aims to present a patient with retrobulbar hematoma due to trauma in zygomatic complex region with no fracture, treated with surgical drainage by lateral cantotomy.
A 28-year-old male patient was referred to the Department of Maxillofacial Surgery in the General Hospital of Nova Iguaçu, with a left zygomatic complex trauma caused by assault. The patient presented ocular proptosis, periorbital edema and ecchymosis, retrobulbar pain, no light perception in the left eye, restriction of ocular motility inferiorly, and diplopia (Fig. 1A). As soon as symptoms were observed, a computed tomography scan examination was performed, showing a suggestive image of retrobulbar hematoma (Fig. 1B).
Pharmacological treatment was started with dexamethasone 4 mg/kg (EMS, Hortolândia, Brazil) and hydrocortisone 100 mg (Pharmacia, Bauru, Brazil), but after 60 minutes with no improvement in visual acuity, the patient was referred to the operating room to surgical drainage through the lateral cantotomy. Straight iris scissors were used to incise the skin and orbicularis muscle at the lateral canthal angle in a horizontal direction extending for 5 mm. Blunt divulsion was then carried to the posterior region of the globe, seeking the complete dissolution of the hematoma. After drainage the hematoma, a simple suture without tension was carried out in the cantotomy region, with careful to avoid occluding completely the drainage pathway. In the postoperative control period, active drainage was observed only in the first day. After 6-month follow-up period, there was an improvement in retrobulbar pain and ophthalmoplegia. The patient recovered the ocular functions and has no complaints. However, the patient still showed deficiency in the pupillary reflex (Fig. 1C).
Although rates of retrobulbar hematoma related to facial trauma are low, early diagnosis must be done to prevent permanent vision loss.5 There are pharmacological methods to treat RBH, and they may be used as an alternative to surgical decompression as acetazolamide 500 mg, hydrocortisone 100 mg, or alternatively a rapid infusion of 20% mannitol.6–8 In patients which nonsurgical treatment is not sufficient to improve the signs and symptoms, surgery management should be considered aiming to increase orbital volume or decrease orbital contents (drainage).
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