Retrobulbar hemorrhage can result in what devastating condition?

  1. Corneal abrasion
  2. Hypopyon
  3. Central retinal artery occlusion (CRAO)
  4. Hyphema
  5. Corneal ulcer

 

 

 

 

Answer:   Central retinal artery occlusion  (CRAO)

Retrobulbar hemorrhage results from ocular trauma almost always seen with some orbital wall fracture (although not all are associated with trauma it is by far most common cause). A sizeable hematoma compress the optic nerve and retinal artery or vein diminishing flow to the retina leading to irreversible blindness if left untreated (as soon as 90 minutes without treatment).

Patients present with a history  trauma of course, ocular pain and proptosis (hematoma pushing the globe out).  Also decreased visual acuity, Afferent pupilary defect, cherry red macular, optic nerve pallor etc. CT will confirm the diagnosis (and in trauma patients with suspected facial trauma you will be getting dedicated orbital CT).

CT finding retrobulbar hemorrhage

 

 

Emergent management includes: Protection of the globe, elevate the head, IV fluids/antiemetics (you don’t want them vomiting and increasing the pressure in the eye) and analgesics. Emergent Lateral Canthotopy to decompress the orbit may be indicated. However ultimately Optho has to be called ASAP as definitive treatment will be performed by them.

Indications for lateral canthotomy: decreased visual acuity, ocular pressure > 40 mmHg, proptosis, afferent papillary defect (Marcus Gunn), Cherry red macular, opthalmoplegia, optic nerve pallor and severe eye pain.

Procedure: Pull down on the lower lid to visualize the tendon, Cut the lateral canthus and extend it toward the orbital rim. Find the superior and inferior crus of the lateral canthal tendon and release the inferior crus from the orbital rim. Recheck pressure if still inadequate (>40 mmHg) repeat with superior crus release.

lateral canthotomy