Retrobulbar Hematoma Research Articles

Analysis of risk factors for patients with traumatic optic neuropathy and comparison of visual outcomes of management strategies

BackgroundTraumatic optic neuropathy (TON) is a rare complication of facial trauma that results in vision loss. Clinical diagnosis of TON is based on a history of head trauma and an ophthalmic examination; however, the risk factors for TON and the ideal treatment strategy remain undetermined. This study investigated the predictive risk factors for TON and analyzed the effectiveness of current treatments with respect to visual outcomes in patients with TON. MethodsThis study retrospectively enrolled patients with periorbital facial bone fracture between 2008 and 2019. Initial facial bone computed tomography, ophthalmic exam results, initial Glasgow Coma Scale, and Injury Severity Score (ISS) were recorded. This study classified patients into 4 intervention groups (i.e., medication, surgery, combination therapy, and observation) to compare the outcome of visual acuity. ResultsThis study enrolled 1168 patients with facial bone fractures, 93 (7.96%) of whom were diagnosed as having TON. Independent risk factors for TON included optic canal fracture, medial orbital wall fracture, retrobulbar hematoma, and head Abbreviated Injury Scale ≥ 4. Patients with TON who initially presented with no light perception tended to have poor final visual acuity (VA) outcomes. The results indicated no significant difference in VA improvement among patients receiving observation, mega-dose corticosteroid therapy, surgical decompression, or combined steroid therapy and decompression. ConclusionClinicians can achieve early prediction of TON in patients with an initial unconscious state and the determined risk factors. The results indicated that conservative observation yielded noninferior VA outcomes in patients with TON compared with those receiving medication or surgical treatment.

A Case of Painful Visual Loss - Managing Orbital Compartment Syndrome in the Emergency Department.

Emergency medicine (EM) residents. This simulation curriculum may also be utilized for senior medical students conducting EM rotations. Ophthalmologic education represents only a small portion of medical school curriculums and continues to decrease over time, leaving physicians poorly equipped to diagnose and manage eye complaints.1 Of emergency physicians (EPs) surveyed, 72.5% felt that they could diagnose orbital compartment syndrome (OCS), yet only 40.3% felt comfortable performing a necessary lateral canthotomy and cantholysis (LCC).2 These survey results demonstrate the urgent need for improved ophthalmology education in EM residency to help us diagnose and manage potentially vision-threatening pathology. By the end of this simulation, learners will be able to: 1) demonstrate the major components and a systematic approach to the emergency ophthalmologic examination, 2) develop a differential diagnosis of sight-threatening etiologies that could cause eye pain or vision loss, 3) demonstrate proficiency in performing potentially vision-saving procedures within the scope of EM practice. Low-fidelity simulation was conducted using a novel model adapted from that used by Phillips et al. during their ophthalmology day in the Department of Emergency Medicine at Vanderbilt University.3 The simulation case was developed by an interdepartmental team of ophthalmologists and EPs at our institution. To evaluate for statistically significant changes in self-efficacy, knowledge, and performance after an educational intervention. Our primary outcome was defined as a checklist-based performance on a simulated case of orbital compartment syndrome necessitating LCC. We conducted a single-center prospective pre- and post-interventional study evaluating the impact of an educational intervention on EM resident management of a simulated case of OCS. Our two-part study intervention consisted of a lecture on OCS followed by a four and a half hour ophthalmology education day (OED). Residents were evaluated using self-efficacy scales (SES), multiple-choice questions (MCQ), and a performance checklist (developed via a modified Delphi process) at three timepoints: Pre-intervention, immediate post-intervention, and three months post-intervention. Post-graduate year (PGY)-1 through PGY-4 EM residents at an Urban Level 1 Trauma Center participated. Initial recruitment consisted of 18 residents (PGY-1 through PGY-4), and 16 residents (PGY-1 through PGY-3) completed the study. Nine residents participated in the OED and seven residents did not. There were no pre-existing differences in median checklist-based performance, MCQ, or SES scores prior to the intervention. At three months post-OED, the OED attendees scored statistically significantly higher on checklist-based performance than non-attendees (lecture only). Ophthalmology education in physician training is limited, and EP comfort with performing vision-saving procedures is poor. We developed a simulation case involving such a vision-saving procedure as well as an ophthalmology curriculum that increased skill retention surrounding management of ophthalmologic emergencies. Emergency medicine (EM), ophthalmology, orbital compartment syndrome (OCS), retrobulbar hematoma, vision loss, eye pain.

Orbital Hematoma Treatment—A Retrospective Study

Background: Bleeding within the orbit in the form of a subperiosteal or retrobulbar hematoma is a relatively common complication of trauma and surgery. It affects up to 30% of patients fractures involving the orbital bones. Most cases do not require surgical intervention because they do not cause retinal ischemia or optic nerve neuropathy. The above symptoms occur in only 0.5–1% of patients developing Orbital Compartment Syndrome (OCS). Due to the short period (60–100 min) of time in which the optic nerve and retina can tolerate increased intraocular pressure, it seemed reasonable to evaluate and standardize the surgical management protocol for this rare complication. Objective: The aim of this retrospective study was to retrospectively analyze cases of inframammary haematomas with clinically relevant correlations. Methods: Eighteen patients treated at the Department of Maxillofacial Surgery due to OCS, in Lodz and Poznan, Poland, between 2009 and 2022, were included. APTT, INR, systemic diseases, cause, location and size of hematoma, presence and number of fractures, visual disturbances and pupillary response on the day after surgery and one month after, the type of intervention and time between admission to the hospital and surgery were evaluated. Results: Statistically significant correlations were obtained between the size of the hematoma and the patients’ age, the degree of visual disturbance and the weakening of pupillary constriction, severe initial symptoms and poor postoperative outcomes at both postoperative periods studied, immediate and distant poor outcome after decompression surgery and good postoperative outcome persisting one month after. Conclusions: The results obtained in the study and the surgical protocol proposed by the authors are in line with the current state of knowledge regarding orbital hematomas. Some of the correlations described in the literature (such as OCS and anticoagulant treatment) were not demonstrated, but this is probably due to the small study group. Maintaining the 100 min limit as a standard was possible only in early postoperative diagnoses (only 1 of the patients was operated on up to 100 min after the appearance of symptoms). In other cases, the specialized diagnosis took an average of 2785 ± 4020 min or 46 ± 67 h.

What are typical presentations of acute retrobulbar hematoma?

What are typical presentations of acute retrobulbar hematoma?

Challenge and strategy in the management of retrobulbar hematoma: A case evaluation

Challenge and strategy in the management of retrobulbar hematoma: A case evaluation

Ambulatory Orbital Fracture Repair: An Analysis of ER Visits After Surgery From a Multistate Study.

To determine the 30-day postoperative emergency room (ER) visit rate following ambulatory orbital fracture repair with same-day discharge, and the causes and risk factors associated with ER visit. Database study. State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) for California, New York, and Florida for 2011. We identified orbital fracture repair procedures among adults from the SASD, which was linked to the SEDD to identify the incidence and causes of ER visits within 30 days. Univariate and multivariable logistic regression models were used to determine the factors associated with ER visit. Among 762 patients, the 30-day postoperative ER visit rate was 4.5%. Most ER visits (58.9%) occurred during the first week after surgery. The most common reasons for ER visits were related to pain, swelling, headache, dizziness, and fatigue (29.4%), followed by ophthalmologic etiologies including visual disturbances and infection of the eye (14.7%). There was no case of retrobulbar hematoma. In the multivariate analysis, patients living in Florida were at a significantly higher risk for ER visit compared to those in California (odds ratio: 4.48 [1.43-14.10], p = .010). Ambulatory orbital fracture repair appears to be safe. Common reasons for ER visit included pain, swelling, and ophthalmic symptoms. An increased risk for ER visit was seen with certain geographic regions but not with medical comorbidities or concurrent facial fractures or procedures.

Globe Rupture Diagnosed with Point-of-Care Ultrasound

Patients presenting to the emergency department (ED) with eye complaints comprise approximately 1.5% of all cases seen in the ED, and of these, up to 34% are related to trauma.1 One of the most concerning diagnoses an emergency physician (EP) must consider in this patient population is globe rupture. It can occur secondary to blunt or penetrating eye trauma or facial trauma. Patients often present with pain, redness, tearing, or decreased vision.2 Findings on ocular examination include shallow anterior chamber, 360° subconjunctival hemorrhage, irregular pupil, iris prolapse, visualization of a protruding foreign body, and Seidel sign.3 However, ophthalmological assessment can be challenging, especially if there is significant periorbital edema and ecchymosis post-trauma. In this setting, the eye can be further evaluated with imaging, either ultrasound or computed tomography (CT) scanning. Diagnostic radiology ultrasound has limited experience with ocular assessment, and CT is not always immediately available and may require patient transport in rural or remote settings. Alternatively, point of care ultrasound (POCUS) is a tool that allows the EP to perform a scan at the bedside to answer a specific clinical question. In the setting of ocular trauma, it can effectively and rapidly diagnose retinal detachment, lens dislocation, retrobulbar hematoma, and globe rupture.4 This case demonstrates the rapid diagnosis of globe rupture with POCUS, expediting the patient's care.

Successful Management of a Spontaneous Retrobulbar Hematoma After Heart Transplantation. A Case Report

We present a case of a 65-year-old patient who underwent heart transplantation. After the surgery, left proptosis, conjunctival chemosis, and ipsilateral palpebral ecchymosis were found while he was still intubated. A retrobulbar hematoma was suspected, confirmed by a computed tomography scan. Initially, expectant management was considered, but with the appearance of an afferent pupillary defect, the patient underwent orbital decompression and posterior collection drainage, which prevented visual impairment. Spontaneous retrobulbar hematoma after heart transplantation is a rare condition that risks vision. We intend to discuss the importance of postoperative ophthalmologic examination after heart transplantation in intubated patients for early diagnosis and rapid treatment. Spontaneous retrobulbar hematoma (SRH) after heart transplantation is an exceptional condition that risks vision. Bleeding in the retrobulbar space provokes an anterior ocular displacement, extending the vessels and the optic nerve, which can generate ischemic neuropathy and, finally, a loss of vision [1]. A retrobulbar hematoma is usually associated with trauma or eye surgery. Though, in non-traumatic cases, the underlying cause is not evident. An adequate ophthalmologic examination is usually not performed in complex surgeries like heart transplantation. However, this simple measure can prevent permanent vision loss. Non-traumatic risk factors should also be considered, which include vascular malformations, bleeding disorders, use of anticoagulants, and increased central venous pressure usually triggered by a Valsalva maneuver [2]. The clinical presentation of SRH consists of ocular pain, decreased visual acuity, conjunctival chemosis, proptosis, abnormal extraocular movements, and elevated intraocular pressure (IOP). Its diagnosis is often clinical; however, it can be confirmed with computed tomography or magnetic resonance imaging. Treatment aims to reduce IOP with surgical decompression or pharmacologic measures [2]. In the reviewed literature, less than 5 spontaneous ocular hemorrhages related to cardiac surgery have been reported [3-6], of which only one is related to heart transplantation [3]. A clinical challenge of an SRH after heart transplantation is presented below. Surgical management was performed with a favorable result.

Complications of transnasal endoscopic orbital decompression in thyroid eye disease

The study evaluates the frequency of complications after transnasal endoscopic orbital decompression (TEOD). The study included 40 patients (75 orbits) with thyroid eye disease (TED; also termed Graves' ophthalmopathy, GO; thyroid-associated orbitopathy, TAO), who were divided into three groups depending on the method of surgical treatment. The first group consisted of 12 patients (21 orbits) who were treated with TEOD as the only method of surgical treatment. In the second group, there were 9 patients (18 orbits) who underwent TEOD and lateral orbital decompression (LOD) simultaneously. The third group consisted of 19 patients (36 orbits) who underwent TEOD as the second stage after LOD. Pre- and postoperative observation included assessment of visual acuity, visual field, exophthalmos, heterotropia/heterophoria angle. In group I the new-onset strabismus with binocular double vision was detected in 1 patient (8.3%). In 5 patients (41.7%), there was an increase in the angle of deviation and an increase in diplopia. In group II the new-onset strabismus with diplopia occurred in 2 patients (22.2%). In 8 patients (88.9%), an increase in the angle of deviation and an increase in diplopia were revealed. In group III the new-onset strabismus and diplopia occurred in 4 patients (21.0%). An increase in the deviation angle and an increase in diplopia were noted in 8 patients (42.1%). The number of postoperative otorhinolaryngologic complications in group I was 4 (19.0% of the number of orbits). Two intraoperative complications were recorded in group II - 1 case of cerebrospinal rhinorrhea (5.5% of the number of orbits) and 1 case of retrobulbar hematoma without permanent vision loss (5.5% of the number of orbits). The number of postoperative complications was 3 (16.7% of the number of orbits). In group III the number of postoperative complications was 3 (8.3% of the number of orbits). The study showed that the most common ophthalmological complication after TEOD is strabismus with binocular double vision. Otorhinolaryngologic complications included synechiae of the nasal cavity, sinusitis and mucocele of the paranasal sinuses.

Retrobulbar Hematoma after an open reduction of blow-out fracture of orbit

62 years old male patient who presented blunt trauma in his right eye with subsequent orbital fracture type impure blow-out who required open reduction of the facial fracture, who presented at the second postoperative day a retrobulbar hematoma with need for surgical intervention of urgency.

Unilateral exophthalmos in a dog following bilateral maxillary nerve block for rhinoscopy

AbstractLocal anaesthetic techniques are utilised to provide analgesia and anaesthesia during rhinoscopy (and biopsy) in small animals. This report describes the incidence and management of exophthalmos in a 1‐year‐old, male, neutered whippet as a consequence of a retrobulbar haematoma, following inadvertent vessel puncture while performing a maxillary nerve block. The patient recovered fully without further complications following conservative management.

ORBITAL LYMPHOMA: A MULTIDISCIPLINARY APPROACH TO DIAGNOSIS AND MANAGEMENT

Non-Hodgkin-type orbital lymphomas are extremely rare. Proptosis, edema, decreased visual acuity, and ocular motility are signs and symptoms. Magnetic resonance imaging (MRI) and computed tomography (CT) assist in the diagnosis, confirmed by biopsy and anatomopathologic exam. Treatment includes radiotherapy, chemotherapy, or their association. The aim of this work was to report a case of an orbital lymphoma. A 67-year-old male patient reported left ocular proptosis, dystopia, visual impairment, and ocular motility for 3 weeks, after local trauma. Retrobulbar hematoma was ruled out after CT evaluation. In discussion with the ophthalmologist, MRI showed a solid mass in the left superior-lateral orbital region. Incisional biopsy was performed under general anesthesia by head and neck surgery and maxillofacial surgery teams. The diagnosis was orbital lymphoma of the extranodal marginal zone. The treatment proposed was chemotherapy, still in progress, and the patient showed improvement in visual signs and symptoms. Non-Hodgkin-type orbital lymphomas are extremely rare. Proptosis, edema, decreased visual acuity, and ocular motility are signs and symptoms. Magnetic resonance imaging (MRI) and computed tomography (CT) assist in the diagnosis, confirmed by biopsy and anatomopathologic exam. Treatment includes radiotherapy, chemotherapy, or their association. The aim of this work was to report a case of an orbital lymphoma. A 67-year-old male patient reported left ocular proptosis, dystopia, visual impairment, and ocular motility for 3 weeks, after local trauma. Retrobulbar hematoma was ruled out after CT evaluation. In discussion with the ophthalmologist, MRI showed a solid mass in the left superior-lateral orbital region. Incisional biopsy was performed under general anesthesia by head and neck surgery and maxillofacial surgery teams. The diagnosis was orbital lymphoma of the extranodal marginal zone. The treatment proposed was chemotherapy, still in progress, and the patient showed improvement in visual signs and symptoms.

South Texas orbital fracture protocol for emergency department evaluation of orbital fractures

PurposeFacial trauma and orbital fractures are common reasons for ophthalmology consultation in the emergency department (ED). The purpose of this study is to assess intervention rates and evaluate the acuity of ophthalmology consultation for orbital fractures in the ED. Basic proceduresA retrospective chart review of orbital fractures was conducted over a 23-month period. 379 cases of orbital fractures were identified in a single-center study. All patients that received an ophthalmology consultation in the ED were included. Demographics, mechanism and location of orbital fracture, ophthalmic complications, and surgical and non-surgical ophthalmic interventions were recorded. The primary study outcome was the rate of ophthalmic consultation and intervention with and without retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP). ResultsImmediate ophthalmic intervention was performed in 18.7% of patients. Statistically significant subjective, radiographic, and physical exam features correlating with ophthalmic intervention were identified and included globe rupture, concern for entrapment, orbital roof fractures, and retrobulbar hematoma. Retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP) would have resulted in 186 of 379 patients requiring ophthalmology consultation, thus reducing consultation rate by 51% with an improved rate of intervention from 18.7% to 37.6%. ConclusionsOrbital fractures can be associated with severe ocular complications. Most cases, however, do not require emergent evaluation by an ophthalmologist. We propose the South Texas Orbital Fracture Protocol (STOP) for proper assessment and triaging of orbital fractures in the ED. While this clinical decision-making tool requires validation, it may offer improved healthcare efficiency, reduced costs, fewer unnecessary inter-facility transfers, and less burnout for ophthalmology residents.

Spontaneous globe subluxation: a case report and review of the literature

BackgroundSpontaneous globe subluxation (SGS) is an atraumatic anterior dislocation of the eyeball. It is exceedingly rare. Understanding SGS predisposing factors may help uncover its etiology and undertake vision-saving management.Case presentationA 48-year-old female presented to the ED with her right eye out of its socket. She reported blurry vision, photophobia, and pain in the affected eye. She was unable to close her right eyelid and was in obvious distress. On arrival, her blood pressure was elevated. Her medical history was notable for hypertension and obesity. On physical examination, extraocular eye movements were not intact, and the globe appeared whole and round. She was also unable to count fingers with the affected eye. There was no visible trauma to the face. Multiple wet gauzes with sterile saline were placed over the displaced eyeball. Direct and even pressure was applied on the globe. Within 30 s, the globe was reduced back in. The patient was able to close her eyelids and reports substantial pain relief with reduction. A CT scan of the orbits was then obtained, demonstrating mild bilateral proptosis. The globes were normal and symmetric. No intraconal or extraconal abscess or infection was seen. There were no intraconal or extraconal masses. There was no acute orbital traumatic injury, no avulsion of the optic nerve, ocular rupture, or retrobulbar hematoma. After reviewing the case with an ophthalmologist, a follow-up appointment with the ophthalmologist was arranged. The patient was discharged on erythromycin ointment. Post-discharge investigation of the CT imaging revealed dilated optic nerve sheaths, tortuosity of the optic nerve, and empty sella.ConclusionsIn addition to causing distress and severe anxiety, SGS poses numerous immediate as well as long-term complications. Traction of the optic nerve and retinal vasculature may potentially cause retinal venous congestion and loss of visual acuity with potential vision loss. In the absence of known risk factors or disease processes, orbital imaging and serological studies for thyroid ophthalmopathy should be considered.

Initial Management of Orbital Trauma: Is an Ophthalmologic Evaluation Necessary?

BACKGROUND: Orbital fractures may be associated with globe injuries, resulting in delayed ophthalmic complications and visual disturbance. The debate regarding the necessity of ophthalmologic evaluation in the initial management of orbital trauma continues. Therefore, there is a need to establish the rate of ocular injuries associated with orbital fractures. METHODS: A retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed tomography scan analysis at a level 1 trauma center, from 2014 to 2020 was performed. The inclusion criteria were patients 18 years or older with confirmed computed tomography scan diagnosis of orbital fracture and ophthalmology consultation. Patient demographics, injuries, comorbidities, and surgical outcomes were collected. RESULTS: A total of 201 patients with 224 orbital fractures (11.4% bilateral) were included. The mean age at injury was 50.5 ± 25.2 years; 21.9% of patients had an associated neurologic injury at the time of ED evaluation. The most common mechanisms of injury were mechanical fall (41%), occupational injuries (26.9%), and motor vehicle accident (25%). The posterior segment of the eye was most affected (16.1%), followed by the anterior segment (13.4%) and ocular adnexa (13.4%). A significant ocular injury was present in 21.9% of orbital fractures. These included choroidal hemorrhage (6.1%), hyphema (5.4%), retinal hemorrhage (4.5%), retrobulbar hematoma (4%), globe rupture (3.6%), choroidal hemorrhage (1.4%), retinal detachment (1.3%), corneal laceration (0.9%), choroidal rupture (0.4%), macular hemorrhage (0.6%), and retinal tear (0.4%). The mechanism of injury was not associated with an increased risk for a serious ocular injury. The most common ophthalmologic findings on examination were diplopia (30.4%), reduced extraocular movement (9.8%), and periorbital laceration (8.9%). Of all patients, 53.1% presented with one orbital wall fracture, of which, the orbital floor was the most commonly involved (44.2%). Associated facial fractures were found in 68.8% of patients. computed tomography scans showed displaced fracture in 44.6% of orbits, comminution in 45.3% and herniation of orbital contents in 42.9%. On multiple variable analysis, motor vehicle accident (OR = 2.5 [1.4–4.7], P = 0.003) and injury to the posterior segment (OR = 2.6 [1.2–5.8], P = 0.045) were associated with the need of surgical treatment. However, injury to the anterior segment (OR = 3.4 [1.5–8.0], P = 0.028) and ocular adnexa (4.0 [1.6–10.1], P = 0.002) were associated with the need of medical treatment alone. CONCLUSIONS: Our retrospective series demonstrated a 22% incidence of ocular trauma in orbital fractures. There were no association between mechanism of injury and serious ocular trauma. This emphasizes that the management of orbital traumas requires a multidisciplinary approach, including the facial trauma team and ophthalmology.

1326 Otorhinolaryngology Education and Training Innovation: A Literature Review of the Academic Year 2019-2020

Abstract Aim We aimed to summarise the literature on educational research and training in otorhinolaryngology during the academic year of 2019-2020. Method A literature search was conducted on Medline, Embase and Cochrane in accordance with PRISMA guidelines for ““(ENT or otorhino* or otolaryngo* or (ear, nose, and throat)) and (educat* or train or training or teach*)””. The search was conducted independently on 13/09/20 by two authors (JOH, JM), any discrepancy was further reviewed by a third author (JC). All original research papers published between 2019-2020 were included. Results 68 papers were included in our study. Educational research this year shifted focus on how to combat the negative impact of COVID-19 on otorhinolaryngology teaching. Although many of the interventions created for postgraduate and undergraduate education have not been formally assessed, virtual electives for medical students were found to increase interest and knowledge in the specialty. Surgical simulation represented the most common teaching method reported aside from COVID-19. 3D models were used for emergency training with an aim to increase trainee exposure to an anterior neck abscess, retrobulbar haematoma and paediatric tracheostomy. 3D models were positively rated for face and content validity and gave statistically significant improvements in confidence for trainees. Conclusions The otorhinolaryngology training in 2019-2020 has changed massively due to the pandemic. Improving on virtual learning and adapting simulation training are the key to maintain a positive learning environment for medical students and doctors in the short term. Research on the effect of COVID-19 on otorhinolaryngology education and training will be the focus in 2021.

Retrobulbar haematoma secondary to haemophilia A in a dog

AbstractA 6‐year‐old male Yorkshire terrier presented due to sudden onset exophthalmos of the left eye. Ocular signs included conjunctival haemorrhage and third eyelid protusion. Physical examination revealed decreased ocular retropulsion and pain on opening the mouth. Skull CT demonstrated the presence of a retrobulbar mass. Transoral drainage of the retrobulbar space disclosed blood, but subsequently to this procedure profuse bleeding occurred from the incision site, while haematocrit levels decreased significantly. Coagulation tests showed a deficiency on the VIII and XII clotting factors, compatible with haemophilia A. As a consequence of exophthalmos, a severe exposure keratitis took place that rapidly evolved to perforation. After fresh frozen plasma administration, a transconjunctival enucleation was performed. Although uncommon, retrobulbar haematoma resulting from haemostatic defects should be included in the differential diagnosis of exophthalmos in dogs.

Volumetric Analysis and Clinical Outcome in 54 Patients with Retrobulbar Hematoma

Retrobulbar hematoma (RBH) is a rare but serious vision threatening emergency. We analyze the relationship between hematoma volume, visual impairment and outcome. Fifty-four patients with RBH receiving orbital decompression were retrospectively included. Volumetric analysis of RBH was performed by semi-automatic segmentation based on preoperative CT scans using ITK-SNAP software. Best corrected visual acuity (BCVA) measurements were obtained and correlated in 2 groups (no light perception (NLP), severe visual impairment) with the hematoma volume. NLP was documented preoperatively in 5/28 and postoperatively in 9/43 patients. Preoperative NLP was significantly associated with a larger hematoma volume (P=.03) and higher hematoma/orbital volume ratio (P=.03). Postoperative severe visual impairment showed significant associations with a larger hematoma volume (P=.02) as well as higher hematoma/orbital volume ratio (P=.02). Eyes with severe visual impairment and large hematoma volumes preoperatively are at high risk of permanent vision loss. Hematoma volume calculation might represent an additional prognostic parameter for visual outcome after RBH.

Utility of non-contrast head computed tomography in poisoned patients.

To investigate the utility of non-contrast head computed tomography (CT) in poisoned patients. A retrospective cohort study of patients referred to a toxicology unit between August 2010 and December 2017. Our database yielded patients who underwent head CT at presentation to the ED. Pre-specified information was compiled from the medical records. There were 6261 presentations of which 1142 underwent head CT (17%). Median age was 41 years, and 437 (38%) were female. There were 492 (43%) recreational ingestions and 466 (41%) deliberate self-poisonings. The commonest agents were sedatives 376 (33%) and opioids 282 (24%); 334 (29%) cases were intubated. Signs of head injury were found in 153 cases (13%) and focal neurological signs in 68 (6%). No acute pathology was reported in 884 head CTs (77%), chronic changes in 193 (17%) and incidental findings in 26 (2%). Acute pathology was found in 39 (4%) patients: 15 with hypoxic-ischaemic injury, three infarctions, nine with intra-cranial haemorrhage, 11 facial bone fractures and one retro-bulbar haematoma. No patient required an immediate surgical intervention, and only one patient had a change to clinical treatment. Acute head CT pathology was associated with at least one of the following clinical features: need for intubation, signs of head injury, seizure, headache, and unexpected neurological signs. Non-contrast head CT is a low-yield investigation in patients presenting with poisoning. Consideration should be given as to whether the clinical presentation is consistent with the expected toxidrome and whether the patient would benefit from head CT.

Retrobulbar hematoma following the repair of an orbital wall fracture: a case series

BackgroundRetrobulbar hematoma is a rare complication after the repair of an orbital wall fracture, but the caution is required because the condition can cause blindness.Case presentationIn this article, 3 cases of retrobulbar hematoma after the surgical repair of an orbital wall fracture are reported. In the first patient, the permanent loss of vision was involved, while in the second patient, the author was able to prevent loss of vision by performing immediate decompression after definite diagnosis and consulting with an ophthalmologist. In the third patient, there was no surgical treatment involved; he recovered on his own without major sequelae.ConclusionsRetrobulbar hematoma is a very serious condition that can result in blindness. Thus, when it is recognized, every effort should be made to preserve the patient’s vision and prevent blindness.