If hemorrhage is limited, not progressive, and does not threaten optic nerve function, close observation can be appropriate.
If vision is threatened and there is progressive tense proptosis, perform urgent canthotomy and cantholysis of the inferior crus of the lateral canthal tendon. This might need to be performed prior to imaging if necessary. If more release is needed, cantholysis of the superior crus of lateral canthal tendon can be performed. If hemorrhage progresses without relief of intraocular pressure, an orbital fracture can be induced for decompression. It is wiser to err on the side of intervention. (Yung, OPRS 1994), (Liu, AJO 1993)
Simultaneously, start medical therapy with acetazolamide 500 mg IV, methylprednisolone 100 mg IV for neuroprotection of the optic nerve, and topical beta-blocker (timolol 0.5% one gtt. q 30 minutes x 2) (Wood, British J Oral and Maxillofac Surg 1989). Consider methylprednisolone 30 mg/kg/q 6 hrs for optic-nerve protection, although benefits are controversial. (Steinsapir, Surv Ophthalmology 1994)
If postoperative bleeding occurred following eyelid, lacrimal, orbital, or sinus surgery, consider orbital exploration to ligate/cauterize source of bleeding.
Consider referral to hematology/oncology to evaluate for blood dyscrasia if spontaneous retrobulbar hemorrhage.
For patients with progressive visual loss, recommend admission for frequent vision checks and consider IV pulse therapy with methylprednisolone 250 mg IV q 6 hrs x 3 day.