Challenge and strategy in the management of retrobulbar hematoma: A case evaluation

The orbital cavity, with its intricate pear-shaped structure, is formed by a complex arrangement of bones and musculature that divides the orbital content into intraconal and extraconal spaces. This delicate anatomy houses crucial structures such as adipose tissue, the lacrimal gland, ciliary ganglion and various vessels and nerves, all protected by the fascia of the extraocular muscles.1 Retrobulbar hematoma, a potentially vision-threatening complication of periorbital trauma, requires prompt recognition of symptoms such as pain, diplopia, ophthalmoplegia, proptosis and reduced visual acuity, which can lead to blindness if left untreated. Diagnosis relies on imaging modalities such as ultrasound or computed tomography to assess the extent of the hematoma and guide treatment urgency and approach. Management involves a careful, multifaceted strategy combining conservative measures, pharmacological interventions and supportive care, with post-surgical monitoring focusing on reducing periorbital pressure and limiting exacerbating activities.2, 3 This case report aimed to elucidate the clinical presentations, diagnostic challenges and treatment strategies associated with retrobulbar hematoma, emphasizing the importance of meticulous post-operative monitoring and a multidisciplinary approach in managing this sight-threatening condition. A 23-year-old female patient was admitted to the emergency room of the General Hospital of Nova Iguaçu (HGNI) following a motorcycle versus car collision. Clinical examination revealed periorbital blepharohematoma in the left region, ophthalmoplegia, epistaxis and complaints of retrobulbar pain in the left eyeball. She was referred to the hospital's imaging department for a computed tomography (CT) scan, which revealed fractures in the floor and medial wall of the left orbit, a left type I naso-orbito-ethmoidal (NOE) fracture and a retrobulbar hematoma. Given the severity of the clinical picture, she was transferred to the surgical centre for drainage and decompression of the hematoma and fixation of the fractures with reconstruction of the orbital walls. The procedure was carried out under general anaesthesia, orotracheal intubation, with coronal and left subtarsal aproach. The orbital cone was incised with a number 15 scalpel blade for hematoma identification, followed by suction drainage. The NOE fracture was reduced and fixed with 1.5-mm plates (NEORTHO—Curitiba, BR), and the orbital walls were reconstructed with a pre-moulded 1.5-mm mesh (NEORTHO—Curitiba, BR). Subsequently, a forced duction test of the said globe showed no muscle entrapment. The incisions were sutured with 4.0 Vicryl for the internal layers and 5.0 nylon for the skin at the subtarsal access and 3.0 at the coronal. The patient was followed up in the outpatient clinic for 6 months, where a satisfactory orbital reconstruction was observed, and the patient exhibited no apparent complications (Figure 1A–F). In the case presented, a 23-year-old female patient was admitted with significant periorbital injuries following a vehicular collision, leading to the identification and subsequent surgical management of a retrobulbar hematoma and facial fractures. This case underscores the criticality of rapid diagnosis and intervention in the management of retrobulbar hematoma, as echoed in the literature, highlighting its potential to cause permanent vision loss if untreated. The occurrence of such hematomas, as derived from various aetiologies including trauma, surgical interventions and specific medical procedures, necessitates vigilant post-operative monitoring and a high index of suspicion following facial injuries to prevent the dire consequences associated with delayed diagnosis.4, 5 The research reviewed indicates that retrobulbar hematoma, though rare, is a significant complication with variable incidence reported in the context of facial trauma and surgical interventions near the orbital region.2, 6 The symptoms, including proptosis, diminished visual acuity, and ophthalmoplegia, signal the urgent need for decompression to alleviate intraconal pressure and prevent lasting damage. Notably, the case corroborates findings from the literature that retrobulbar haemorrhage, primarily resulting from vascular disruptions within the orbit, demands immediate and effective management to mitigate the risk of permanent visual impairment. Furthermore, the efficacy of lateral canthotomy and cantholysis alongside orbital decompression in the presented case is consistent with recommended practices for reducing intraconal pressure, showcasing the importance of such interventions in the successful treatment of retrobulbar hematomas.2 Conclusively, this case report, juxtaposed with the reviewed literature, reinforces the imperative for oral and maxillofacial surgeons to maintain a high degree of clinical vigilance for retrobulbar hematoma in patients presenting with facial trauma. It highlights the necessity for prompt assessment and intervention to prevent irreversible complications such as blindness. The findings advocate for a multidisciplinary approach, incorporating swift diagnostic imaging and therapeutic measures, including surgical decompression, to address the acute management of retrobulbar hematoma effectively. The case serves as a poignant reminder of the critical role that timely recognition and treatment play in preserving visual function following orbital injuries, underscoring the essential need for ongoing education and awareness among surgical professionals regarding this potentially vision-threatening condition. The authors declare no conflict of interest. We thank FAPERJ - Programa Jovem Cientista Nosso Estado, for the finantial support which enabled the authors to develop this study (process number 201.401/2022).