Retrobulbar Hemorrhage

Craig D. Lewis; Julian D. Perry

Expert Rev Ophthalmol. 2007;2(04):557-570.

Abstract and Introduction

Abstract

Retrobulbar hemorrhage is an uncommon, vision-threatening complication of orbit and eyelid surgery. We review the incidence of retrobulbar hemorrhage, risk factors, orbital anatomy, pathophysiology, diagnosis and treatment options. Preoperative, intraoperative and postoperative measures to prevent retrobulbar hemorrhage are discussed, and a treatment algorithm is presented.

Introduction

Retrobulbar hemorrhage represents a rare, vision-threatening complication of orbital and eyelid surgery.

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Table 1. Etiology of Retrobulbar Hemorrhage
Etiology	Incidence
Spontaneous
Orbital vascular abnormality	Case Reports
Uncontrolled hypertension	Case Reports
Coagulopathy	Case Reports
Septicemia	Case Reports
Vigorous activity	Case Reports
Post-traumatic
Orbital fractures	RH: 0.45-0.6%; VL(RH): 0.17-0. 56%
Postanesthesia
Retrobulbar injection	RH: 0.005-0.44%
Peribulbar injection	Case Reports
Sub-Tenon’s injection	Case Reports
Postoperative
Facial fracture repair	RH: 0.242-0.3%
Blepharoplasty	RH: 0.055%; VL(RH): 0.0045%
Endoscopic sinus surgery	RH: 0.43%
Other surgeries: strabismus surgery, glaucoma valve implant, dacryocystectomy, coil embolization of dural sinus fistula, ICA aneurysm repair, third molar extraction	Case reports
Endotracheal intubation	Case reports

ICA: Internal carotid artery; RH: Retrobulbar hemorrhage; VL(RH): Vision loss attributed to RH.

Box 1. Risk Factors Associated with Retrobulbar Hemorrhage
Systemic disease
Hypertension Vascular disease Coagulopathy Dyscrasias (thrombocytopenia, cirrhosis and leukemia)
Medications
Anticoagulants (coumadin and heparin) Antiplatelet medications (aspirin, NSAIDs and clopidogrel)
Activity/positioning
Valsalva manuevers (vomiting and coughing) Maintaining dependent head position Increased/vigorous activity

Table 2. Orbital Foramina and Transmitted Structures
Foramina	Vasculature	Nerves
Optic canal	Ophthalmic artery	CN II
Superior orbital fissure	Superior orbital vein, orbital branch of the middle meningeal artery, recurrent branch of the lacrimal artery	CN III, CN IV, branches of CN V3
Inferior orbital fissure	Inferior ophthalmic vein(s)	Branches of CN V2, sympathetic innervation of the lacrimal gland
Infraorbital canal	Infraorbital artery	Infraorbital nerve
Anterior ethmoidal foramina	Anterior ethmoidal artery
Posterior ethmoidal foramina	Posterior ethmoidal artery
Zygomaticofacial canal	Zygomaticofacial artery	Zygomaticofacial nerve
Zygomaticotemporal canal	Zygomaticotemporal artery	Zygomaticotemporal nerve
Meningeal foramen	Recurrent meningeal branch of the middle meningeal artery

CN II: Optic nerve; CN III: Oculomotor nerve; CN IV: Trochlear nerve; CN V2: Maxillary division of trigeminal nerve; CN V3: Ophthalmic division of trigeminal nerve.
CN: Cranial nerve.

Table 3. Over-The-Counter Medications and Supplements with Potential Anticoagulant Function
Class	Medications
Aspirin	Acuprin 81^®, Bayer Aspirin^®, Bufferin^®, Easprin^®, Ecotrin^®, Empirin^®, Halfprin^®, Norwich Aspirin^®, St Joseph Aspirin^® and Zorprin^®
NSAIDs
Ibuprofen	Advil^®, Advil Allergy Sinus, Advil Cold, Advil Cold and Sinus, Advil Migraine, Cap-Profen^®, Children's Advil Allergy Sinus, Children's Elixsure^®, Children's Motrin Cold^®, Excedrin IB^®, Genpril^®, Ibuprin^®, Ibuprohm^®, Ibuprohm Cold and Sinus^®, Ibu-Tab 200^®, Liqui-gels, Medipren^®, Midol 200^®, Midol IB^®, Motrin^®, Motrin IB^®, Motrin Migraine Pain, Nuprin^®, Pamprin IB^®, Pediacare Fever^®, PediaProfen^®, Profen^®, Rufen^®, Saleto 200^® and 400^®, Sine-Aid IB^®, Tab-Profen^®, Trendar^® and Uni-Pro^®
Ketoprofen	Actron^®, Ketoprofen^® and Orudis KT^®
Naproxen	Aleve^®, Anaprox^®, Anaprox DS^®, EC-Naproxyn^®, Naprelan^® and Naprosyn^®
Supplements
Vitamin supplements	Vitamin E, vitamin A
Herbal supplements	Arnica, bromelain, dong quai, feverfew, garlic, ginkgo, ginger, ginseng, licorice, omega-3 fatty acids and saw palmetto

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Retrobulbar Hemorrhage

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