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Retrobulbar Hemorrhage

CRITICAL — Trauma

Symptoms

  • severe orbital pain and pressure
  • sudden, progressive vision loss
  • inability to open eyelids due to extreme swelling
  • history of recent trauma, eyelid surgery, or orbital injection
  • use of anticoagulants (warfarin, eliquis, aspirin)

Clinical Findings

Orbital compartment syndrome (OCS)

  • proptosis: "rock hard" globe with total resistance to retropulsion
  • tense eyelids: nearly impossible to evert or open manually
  • motility: limited extraocular movement in all fields (frozen globe)
  • external: diffuse subconjunctival hemorrhage and chemosis

Optic nerve & vascular signs

  • afferent pupillary defect (rapd) and loss of color vision
  • intraocular pressure (iop): often >40–50 mmHg
  • fundus: disc swelling or pulsations/occlusion of the central retinal artery

Etiology

Pathophysiology

  • the orbit is a fixed bony space; rapid bleeding increases pressure
  • orbital compartment syndrome: pressure exceeds perfusion, killing the optic nerve
  • ischemic tolerance: permanent damage occurs within ~90 minutes

Common triggers

  • trauma (orbital wall fractures, blunt force)
  • surgery (blepharoplasty, sinus surgery, retrobulbar blocks)
  • spontaneous: in patients with bleeding disorders or severe hypertension

Red Flags

  • do not wait for imaging: if vision is failing and the globe is "rock hard," decompress immediately
  • iop >40 mmHg + rapd: pathognomonic for urgent surgical decompression
  • "teardrop" or "tented" globe on ct: indicates the optic nerve is at maximum stretch

Investigations

Clinical priority

  • visual acuity and rapd check: the most important monitoring tools
  • iop measurement: confirm elevation to justify surgical intervention

Imaging (secondary)

  • ct orbit (axial/coronal): useful AFTER decompression to find the source
  • look for "tenting" of the posterior globe (posterior angle <130°)

Treatment

Bedside decompression (canthotomy)

  • instruments: hemostat, blunt-tipped scissors (stevens/westcott), and toothed forceps
  • 1. canthotomy: cut the lateral canthal angle (skin to conjunctiva)
  • 2. cantholysis: identify and cut the inferior crus of the canthal tendon
  • indicator of success: the lower eyelid should fully release from the globe

Medical adjuncts

  • head elevation (45°) and ice compresses
  • iop drops: timolol, brimonidine, or dorzolamide
  • systemic: iv methylprednisolone to reduce orbital soft tissue edema

Clinical Pearl

Retrobulbar hemorrhage = orbital compartment syndrome. Vision loss is permanent within 60–90 minutes if untreated. Lateral canthotomy is a life-of-the-eye procedure that any physician must know how to perform.

Differential Diagnosis

  • • orbital cellulitis (fever, elevated wbc, infectious history)
  • • orbital emphysema (history of sneezing after sinus fracture; crepitus)
  • • carotid-cavernous sinus fistula (bruit, pulsatile proptosis)

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