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January 2011

 
Ophthalmic Pearls: Orbit
Evaluation and Management of Orbital Hemorrhage
By Tiffany L. Kent, MD, PHD, and Carrie L. Morris, MD
Edited by Ingrid U. Scott, MD, MPH, and Sharon Fekrat, MD
 
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When a patient presents with an orbital hemorrhage, evaluation and treatment must be prompt to ensure the best possible outcome. Patients with orbital hemorrhage often have a rapid progression of symptoms, and regardless of whether the bleeding is preseptal or postseptal, the hemorrhage can be dramatic, which often causes anxiety for the patient as well as the clinician. Determining both the location of the hemorrhage and the etiologic mechanism is essential for providing the most appropriate intervention, and requires a thorough understanding of the orbital and periorbital anatomy.

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Anatomy

The orbital septum is a fibrous sheath that arises from the periosteum of the orbital rims. Superiorly, the orbital septum descends and fuses with the levator aponeurosis, whereas inferiorly, the septum ascends and fuses with the capsulopalpebral fascia. In both the upper and lower eyelids, the orbital septum creates two anatomical layers, the preseptal and postseptal spaces. An acute hemorrhage in the preseptal space, while dramatic in appearance, may not be as vision-threatening as a postseptal hemorrhage. Bounded anteriorly by the septum, the postseptal orbital space can accumulate blood and create a compartment syndrome, thereby damaging the enclosed structures—most important, the optic nerve and the blood supply to the eye.

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Evaluation

Evaluation of the patient hinges on determining the mechanism leading to the hemorrhage. Blunt trauma can cause orbital hemorrhage. Most commonly, periorbital ecchymoses with eyelid hematomas are encountered after trauma. However, even these hemorrhages can accumulate postseptally, resulting in an ophthalmic emergency. So clinicians should have a high index of suspicion in all trauma patients, especially those taking anticoagulative medication.1–3 Aside from accidental trauma, potential etiologies of orbital hemorrhage include orbit or eyelid surgery, peribulbar injections, orbital varices, lymphangiomas and arteriovenous malformations, anticoagulative medication, blood dyscrasias (e.g., sickle cell anemia), orbital pseudotumor and idiopathic factors. Before eyelid or orbital surgery, the patient should be counseled regarding the rare but serious risk of orbital hemorrhage. If an orbital hemorrhage has no identifiable cause, then the orbit should be imaged for possible vascular tumors and inflammation.

Upon encountering a patient with an orbital hemorrhage, one should quickly obtain a brief medical history identifying the mechanism of hemorrhage (e.g., recent surgery, accidental trauma, spontaneous, etc.). Visual acuity should be measured, and the pupils carefully assessed. The presence of a presumably new afferent pupillary defect (APD) suggests a compressive optic neuropathy from retrobulbar hemorrhage. Since the presence of a retrobulbar hemorrhage (Fig. 1) may restrict global motility in the affected eye and increase the IOP, assessing both extraocular muscle motility and IOP are key to determining the severity of the hemorrhage.

In cases of trauma, patients are often unconscious, intubated and sedated. In such situations, pupils and IOP can be assessed, and an orbital CT scan may provide supplemental information. And the ophthalmologist must be ready to perform a lateral canthotomy and cantholysis, given the low risk-to-benefit ratio of that intervention.

Imaging and tests. An orbital hemorrhage and its relationship to the globe and other orbital structures can be assessed with a CT scan of the orbits (Fig. 2). Contrast is not required for the scan. Laboratory studies, including a CBC to check for hemoglobin and platelet levels, prothrombin time, partial thromoboplastin time, coagulant response time and a factor Xa assay, can also provide coagulation status of the patient. And it should be noted whether the patient is taking any anticoagulants such as warfarin, nonsteroidal anti-inflammatory drugs like aspirin, herbal agents or other platelet-interfering analogs. If canthotomy and cantholysis are needed, these interventions should not be delayed to perform laboratory tests.

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Management

To manage a patient with an orbital hemorrhage, the anatomical localization of the blood is essential.

Preseptal hemorrhage. If the orbital hemorrhage occurs in the preseptal space, the clinician has the option of observing the hematoma or draining it. If the preseptal hematoma is expanding rapidly, then making a small drainage incision would be acceptable therapy. However, if the hemorrhage is stable, observation is appropriate, provided that the patient is not worsening clinically.

Postseptal hemorrhage. A postseptal orbital hemorrhage is a much more precarious situation for the patient.

  • In the presence of an APD, decreased vision, elevated IOP, proptosis or impaired extraocular movements, a lateral canthotomy and cantholysis should be performed immediately to protect the orbital tissues from damage resulting from compartment syndrome.
     
  • If a patient has an orbital hemorrhage but not an APD, elevated IOP or decreased vision, then the hemorrhage may be observed closely, assessing vision, pupils and IOP frequently. If at any point the patient worsens clinically, a canthotomy and cantholysis should be performed. It is much easier to repair a detached canthus than to treat a vascular occlusion, which can occur in the setting of an orbital hemorrhage.
     
  • If a patient has a postsurgical eyelid or orbital wound, then the operative wound should be evacuated to remove the hemorrhage, and possibly a canthotomy and cantholysis should be performed.

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Canthotomy and Cantholysis

The clinician should be prepared to release postseptal orbital blood using a canthotomy and cantholysis. If an expanding postseptal orbital hemorrhage is missed, the results can be deleterious to the patient’s visual potential in the affected eye.

Canthotomy. To perform a canthotomy, make a lateral skin incision at the angle of the lateral canthus. Dissect down to the canthal tendons using sharp dissection.

Cantholysis. To perform an inferior cantholysis, the surgeon should angle Westcott or blunt iris scissor tips downward, away from the globe, parallel to the direction of the intact superior crus of the lateral canthal tendon between the skin and conjunctiva. In one motion, cut down to the lateral orbital rim and sever the inferior crus of the lateral canthal tendon. Strum the inferior crus of the lateral canthal tendon to determine whether any attachments remain between the eyelid and the orbital rim. Cut any remaining attachments to free the lower eyelid adequately and to release entrapped orbital blood. Gentle pressure on the globe will allow any blood to egress passively from the orbit.

Follow-up. Observation of the pupil may reveal the return of reactivity to light and improvement in vision. If the patient’s signs and symptoms are not relieved adequately, consider performing a superior cantholysis in a similar way. Patients must be monitored closely following canthotomy/cantholysis to ensure that symptoms resolve. If there is no improvement, consider a more extensive orbital evacuation in the operating room. The ophthalmologist must keep in mind the possibility that a traumatic optic neuropathy may be present concurrently in the setting of orbital trauma.

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Conclusion

To ensure the best possible outcome for a patient with an orbital hemorrhage, the clinician must proceed with evaluation promptly. Determining the cause of the orbital hemorrhage will aid in the prioritization of procedures to relieve the hemorrhage. A preseptal hemorrhage can be drained through an eyelid incision, while a vision-threatening postseptal hemorrhage calls for frequent monitoring and possible orbital evacuation. The clinician should have a very low threshold for performing a canthotomy and cantho-lysis, since the consequences of waiting can be harmful to the patient’s vision and ocular motility.
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1 Jamal, B. T. et al. J Oral Maxillofac Surg 2009;67:1416–1419.
2 Scott, M. and A. Thomson. J Am Geriatr Soc 2009;57:568–569.
3 Hass, A. N. et al. Ophthal Plast Reconstr Surg 2004;20:426–432.
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Dr. Kent is a resident at Washington University in St. Louis, and Dr. Morris is a private practitioner in Melbourne, Fla.

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