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Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 31

Retrobulbar hemorrhage: A complication to remember

Department of Ophthalmic Plastic Surgery, Fundación Oftalmologica Nacional; Universidad del Rosario, School of Medicine and health Sciences, Bogotá, Colombia

Date of Submission22-Mar-2022
Date of Decision17-Apr-2022
Date of Acceptance20-Apr-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Maria Alejandra Martinez-Ceballos
Calle 50 # 13-50, Bogotá
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_21_22

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Retrobulbar hemorrhage (RBH) is an ophthalmological complication with the potential risk of irreversible blindness due to the compressive effect on the optic nerve. Cases of patients with a history of antiaggregation and/or anticoagulation therapy and RBH have been reported in the literature; ophthalmologists should keep this antecedent in mind and consider the risk–benefit of surgery while working in conjunction with the area of anesthesia to establish the times when medication is suspended or initiated. Similarly, early and timely identification of signs and symptoms related to this complication improves patients' visual prognosis. The following describes the case of a patient who had RBH associated with the use of antiplatelet therapy.

Keywords: Optic nerve, orbit, platelet aggregation inhibitors, retrobulbar hemorrhage

How to cite this article:
Guzman AM, Martinez-Ceballos MA, Hoz JD. Retrobulbar hemorrhage: A complication to remember. Pan Am J Ophthalmol 2022;4:31

How to cite this URL:
Guzman AM, Martinez-Ceballos MA, Hoz JD. Retrobulbar hemorrhage: A complication to remember. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 Mar 23];4:31. Available from: https://www.thepajo.org/text.asp?2022/4/1/31/348002

  Introduction Top

Retrobulbar hemorrhage (RBH) is defined as the accumulation of hematic content in the retrobulbar space, which is behind the eyeball surrounding the optic nerve. RBH is a rare but devastating ophthalmological complication.[1],[2]

The etiology of RBH is diverse. It includes orbital trauma,[3],[4] ophthalmological or maxillofacial surgical procedures,[5],[6] arteriovenous malformations,[7] clotting disorders associated with systemic diseases,[8],[9],[10] and may appear as an adverse event due to anticoagulant or antiaggregate therapies.[11]

The overall incidence of RBH is estimated to be <1%. However, in the case of orbital fractures, the literature reports an incidence of 3.6% to 32.2%.[1],[4] Although RBH cases are low compared to other ophthalmological complications, the association between complete vision loss and RBH is between 29% and 48%.[1],[5]

The pathophysiology of this disorder is based on increased pressure in the orbit resulting in altered arterial circulation and venous return as well as mechanical compression of all structures. The different clinical manifestations that guide the diagnosis are derived from eye pain, diplopia, decreased visual acuity, decreased contrast sensitivity, sudden proptosis, ophthalmoplegia, chemosis, afferent pupil defect by compression of the optic nerve or occlusion of the central artery and/or vein of the retina, and increased intraocular pressure.[2],[12]

  Materials and Methods Top

Literature review

After searching for pertinent articles on PubMed, a brief literature review with an ending date of November 14, 2020, the Medical Subject Heading terms and Boolean operators (AND OR NOT) were used. Filters for human and observational and analytical studies were applied. No filters were applied for the age of patients.

Articles that included the search terms in the title or abstracts that mentioned possible causes of RBH were selected. Articles that were literature reviews or letters to the editor had insufficient patient data or were written in languages other than English or Spanish were excluded. In addition, data related to the year of publication and type of study, socio-demographic variables such as age and gender, RBH-specific data such as cause and affected eye, and the use or nonuse of anticoagulants or antiplatelets were obtained. The information was recorded on a Microsoft Excel Table® and reported as absolute frequencies, central trends, or dispersion measurements in the case of quantitative variables.

In addition, an anonymous e-mail survey was done at an Ophthalmology Reference Center in Bogota, Colombia, as a primary data source to assess the percentage of RBH cases the doctors had seen during their professional careers.

Clinical case

After a functional surgical procedure, a 79-year-old male patient from San Andres Island, Colombia, who had a history of coronary heart disease and was treated with carvedilol and acetylsalicylic acid (ASA), was followed up. The patient had secondary epiphora due to a failure in the pumping mechanism caused by horizontal laxity in his eyelids associated with pseudoherniation of the inferior orbital fat pads. Therefore, he was scheduled for transcutaneous lower eyelid blepharoplasty and correction of the ectropion. Surgery was done on the lower left eyelid without complications.

During the procedure on the lower right eyelid, significant pain was felt after a skin incision and orbicular dissection with the scalpel. The pain did not go away with the application of an additional dose of 2% xylocaine with epinephrine. Soft monopolar electrocoagulation was done. The physical examination revealed tissue tension and right proptosis while pupil reflex and ocular motility enjoyed unrestricted movement. Lateral canthotomy was carried out: A 1 cm lateral skin incision was made protracted laterally and caudally 7–8 mm. Monopolar electrocoagulation was done. Lateral canthal tendon insertion was identified in Whitnall's tubercle. It was sharply dissected, and the inferior lateral canthal tendon was cut. Surgical wounds were left open but gently held together with Steri-Strips®. The pain disappeared after the procedure, and pupillary reflex and ocular motility were not compromised [Figure 1].
Figure 1: Patient with chemosis, subconjunctival hemorrhage, tissue tension, and right proptosis. Postoperative follow-up of canthotomy and cantholysis in the right eye

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A postoperative follow-up was done, and the patient was found to have 20/20 visual acuity without correction in both eyes. Surgery was done again to close the wound 8 days later.

  Results Top

Literature review

A total of 335 articles were found [Appendix 1], and 43 met the inclusion criteria. As for study design, there are 38 case reports, four case series, and one cohort study. The total population included 118 patients and 118 eyes; 91.5% were unilaterally compromised. The male sex was the most prevalent with 70%, and the median age was 52 interquartile range (0.012). The most frequently published cause of RBH was blunt eye trauma with 11 articles (26%), followed by retrobulbar anesthesia with nine articles (21%), and blepharoplasty and spontaneous RBH with five articles each (11.6%). However, most patients were in the Kallio et al. cohort. In this study, 55 patients had RBH as a complication of retro or peribulbar anesthesia.[13]

About 18 articles (35%) reported that patients received treatment with anticoagulants or antiaggregates concerning the pharmacological background, for example, Vitamin K inhibitors, low-molecular-weight heparins, tissue plasminogen activators, ASA, and GP IIb-IIa complex inhibitors are described. Two studies stated that heparin and ASA were discontinued 48 h before surgery. In addition, the anticoagulant effect with protamine sulfate was reversed in one of the studies.

Two cases of RBH-associated thrombophilia, in turn, were mentioned as hemophilia A and acquired factor VIII inhibitor.

Survey results

As for the survey results done at a Reference Center In Ophthalmology, a group of 35 ophthalmologists, 25% of them general ophthalmologists and 75% specialists, responded to the questions. Of the total, 34% of the respondents had cases of RBH, and in 33% of these cases, the most frequent etiology was trauma.

  Discussion Top

Most studies corresponded to case reports and case series. Unfortunately, research with large sample sizes is scarce, making it difficult to establish the incidence of RBH.

Data in Colombia coincide with what has been previously described in the literature worldwide regarding sex, age, and laterality.[14] The age of presentation is in adulthood. Unilateral eye compromise was the most common finding. Three of the four cases with bilateral compromise were related to systemic conditions. According to what was found in the literature [Appendix 2], most RBH-related causes are associated with blunt eye trauma with or without orbital fracture and a history of Sub-Tenon, peribulbar, or retrobulbar local anesthesia. Blepharoplasty, cataract surgery, orbital fracture repair, and strabismus surgery have also been associated with RBH.

Concerning the factors associated with RBH outcomes, in a systematic review of the literature done by Christie et al. that included a logistic regression analysis, the authors found that the risk factors for a worse RBH visual prognosis were advanced age, trauma, ophthalmoplegia, and pupil defect. However, when a young adult had RBH due to a surgical complication, the presence of proptosis and a marked decrease in visual acuity had better visual outcomes. The Last two variables are associated with a better visual prognosis, because they are severe symptoms that require immediate intervention.[15]

In the older adult population, the pathological backgrounds, such as coagulopathies in young patients and the use of antiplatelet and/or anticoagulants, including ASA and heparins, must be documented. The patient, in our case, was given a preanesthetic evaluation, but the physician did not consider suspending the antiaggregant therapy. Based on this, the ophthalmologist should factor in the pathological and pharmacological history and work with anesthesiologists to determine the risk–benefit of surgery, whether or not to continue anticoagulation and/or antiaggregation therapy and evaluate when to discontinue the medication. This also highlights the importance of close postoperative follow-up on patients with the history mentioned above, as RBH may occur up to 7 days after the surgical procedure.[16],[17],[18],[19] Considering the evidence and experience available, we believe that managing anticoagulation treatment before surgery could potentially decrease the risk of an RBH.

Diagnostic imaging is a valuable tool but is not recommended. RBH is a sight-threatening condition that can have devastating outcomes if not treated immediately.

Canthotomy and cantholysis [Figure 2] are effective methods for urgent orbital decompression.[20] In the case of our patient, the clinical manifestations were intraoperative, were quickly identified, and the procedure was done promptly. Fortunately, the visual recovery was 100%. In a retrospective study done by Bailey et al.,[21] the visual outcome in 15 patients with RBH and the time during which their clinical picture developed before surgery was evaluated. There was an improvement in posttreatment visual acuity for 11 of the 15 patients. Although the average time needed to ensure vision recovery is 3 h,[22] Bailey et al., in their series of patients, found that even after 9 h, there may be a gain in visual acuity. However, an inversely proportional relationship is reported between the time when RBH occurs and the time when canthotomy and cantholysis are done.
Figure 2: (These were designed by the authors and drawn by Barón, Y). (a). Local anesthesia (syringe with 25G) 1–2 cc of 1%–2% lidocaine with epinephrine injected into the lateral canthus. (b). Apply electrocoagulation from the lateral canthus toward the bony orbit for 30–90 s. (c). Make a 1–2 cm incision through the skin and lateral canthus. (d). Using forceps, pull the lower lid down to expose the inferior lateral canthal tendon, and (e). Cut through the inferior lateral canthal tendon

Click here to view

  Conclusion Top

Based on the results reported in the literature and the findings obtained in the survey, the conclusion can be drawn that ophthalmologists should assess the urgency of performing surgery on patients who cannot suspend their antiplatelet medication, know the presentation of RBH, and be trained to do the treatment as soon as possible to ensure no visual loss.

Learning points

  • RBH is an ophthalmological complication with a potential risk of irreversible blindness
  • The etiology of RBH is diverse. It includes ocular trauma, local anesthesia, and ophthalmological surgeries
  • The ophthalmologist should keep in mind the pathological and pharmacological history and work with anesthesiologists to determine the risk–benefit of the surgery and whether or not to continue with anticoagulation and/or antiaggregation
  • Canthotomy and cantholysis are effective methods for urgent orbital decompression.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fattahi T, Brewer K, Retana A, Ogledzki M. Incidence of retrobulbar hemorrhage in the emergency department. J Oral Maxillofac Surg 2014;72:2500-2.  Back to cited text no. 1
McCallum E, Keren S, Lapira M, Norris JH. Orbital compartment syndrome: An update with review of the literature. Clin Ophthalmol 2019;13:2189-94.  Back to cited text no. 2
Gosau M, Schöneich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures-complications, outcome, and review of literature. Clin Oral Investig 2011;15:305-13.  Back to cited text no. 3
Kondoff M, Nassrallah G, Ross M, Deschênes J. Incidence and outcomes of retrobulbar hematoma diagnosed by computed tomography in cases of orbital fracture. Can J Ophthalmol 2019;54:606-10.  Back to cited text no. 4
Jacobs SM, McInnis CP, Kapeles M, Chang SH. Incidence, risk factors, and management of blindness after orbital surgery. Ophthalmology 2018;125:1100-8.  Back to cited text no. 5
Kansakar P, Sundar G. Vision loss associated with orbital surgery – A major review. Orbit 2020;39:197-208.  Back to cited text no. 6
Rose GE, Verity DH. Acute presentation of vascular disease within the orbit-a descriptive synopsis of mechanisms. Eye (Lond) 2013;27:299-307.  Back to cited text no. 7
Goyal S, Goel R. Orbital haemorrhage with loss of vision in a patient with disseminated intravascular coagulation and prostatic carcinoma. Orbit 2004;23:193-7.  Back to cited text no. 8
Nemiroff J, Baharestani S, Juthani VV, Klein KS, Zoumalan C. Cirrhosis-related coagulopathy resulting in disseminated intravascular coagulation and spontaneous orbital hemorrhages. Orbit 2014;33:372-4.  Back to cited text no. 9
Sousa FC, Pinto Medeiros J, Marques R, Marques-Neves C. Spontaneous retrobulbar haemorrhage in idiopathic thrombocytopenic purpura. BMJ Case Rep 2017;2017:r-223028.  Back to cited text no. 10
Berg BI, Flury E, Thieringer FM, Augello M, Savic M, Schötzau A, et al. Retrobulbar haematoma in the era of anticoagulants. Injury 2019;50:1641-8.  Back to cited text no. 11
Erickson BP, Garcia GA. Evidence-based algorithm for the management of acute traumatic retrobulbar haemorrhage. Br J Oral Maxillofac Surg 2020;58:1091-6.  Back to cited text no. 12
Kallio H, Paloheimo M, Maunuksela EL. Haemorrhage and risk factors associated with retrobulbar/peribulbar block: A prospective study in 1383 patients. Br J Anaesth 2000;85:708-11.  Back to cited text no. 13
Cabrera Pérez M, Martínez-Ceballos MA, Cáceres Duque N. Clinical and epidemiological profile of ocular emergencies in a large teaching hospital. Rev Mex Oftalmol 2020;94:12-8.  Back to cited text no. 14
Christie B, Block L, Ma Y, Wick A, Afifi A. Retrobulbar hematoma: A systematic review of factors related to outcomes. J Plast Reconstr Aesthet Surg 2018;71:155-61.  Back to cited text no. 15
Ghufoor K, Sandhu G, Sutcliffe J. Delayed onset of retrobulbar haemorrhage following severe head injury: A case report and review. Injury 1998;29:139-41.  Back to cited text no. 16
Cruz AA, Andó A, Monteiro CA, Elias J Jr. Delayed retrobulbar hematoma after blepharoplasty. Ophthalmic Plast Reconstr Surg 2001;17:126-30.  Back to cited text no. 17
Jaru-Ampornpan P, Joseph SS, Grisolia ABD, Briceno CA. Warfarin-associated delayed orbital hemorrhage after orbital fracture repair with smooth nylon foil implant. Orbit 2019;38:519-23.  Back to cited text no. 18
Grumbine FL, Deparis SW, Kersten RC, Vagefi MR. Delayed periocular hemorrhage after upper blepharoplasty. Orbit 2015;34:103-5.  Back to cited text no. 19
Goodall KL, Brahma A, Bates A, Leatherbarrow B. Lateral canthotomy and inferior cantholysis: An effective method of urgent orbital decompression for sight threatening acute retrobulbar haemorrhage. Injury 1999;30:485-90.  Back to cited text no. 20
Bailey LA, van Brummen AJ, Ghergherehchi LM, Chuang AZ, Richani K, Phillips ME. Visual outcomes of patients with retrobulbar hemorrhage undergoing lateral canthotomy and cantholysis. Ophthalmic Plast Reconstr Surg 2019;35:586-9.  Back to cited text no. 21
Hayreh SS, Weingeist TA. Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia. Br J Ophthalmol 1980;64:818-25.  Back to cited text no. 22


  [Figure 1], [Figure 2]


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