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Retrobulbar haemorrhage

A summary of Retrobulbar Haemorrhage, Neurological Pathophysiology has not been discussed elaborately.

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Retrobulbar haemorrhage

  1. 1. Retrobulbar Haemorrhage Dr Rudraprasad Chakraborty 1st Year PG Student Department of Oral & Maxillofacial Surgery Rama Dental College Hospital And Research Centre Kanpur, UP 15/04/15
  2. 2. Inclusions • Introduction • Etiology • Relevant Anatomy • Clinical Features • Treatment
  3. 3. Introduction Massive retrobulbar hemorrhage in the posterior region of the muscle cone, triggered by vessel disruption, leads to progressive exophthalmus with concurrent pupil dilatation, reduced vision and increased intraocular pressure. (Ord 1981; Ord and El Altar 1982) Retrobulbar hemorrhage may occur spontaneously or as a result of trauma, peribulbar or retrobulbar injections, or surgery.
  4. 4. A Retrobulbar hemorrhage is a space-occupying lesion of the orbit leading to forward displacement of these structures as intraorbital volume and pressure increases. Neurological damage is caused by direct compression, by bony fragments or by an indirect compression of the nerves caused by hemorrhage (Rowe and Williams 1985)
  5. 5. Etiology Spontaneous : Orbital vascular abnormality Uncontrolled hypertension Coagulopathy Septicemia Vigorous activity Post Traumatic : Orbital Fractures High Level Midfacial Fracture Le Fort III Fracture
  6. 6. Post Anaesthesia : Retrobulbar injection Peribulbar injection Sub-Tenon’s injection(episcleral ) Post Operative : Facial /Orbital Fracture, Repair Blepheroplasty Endoscopic Sinus Surgery Other surgeries: Strabismus surgery, Glaucoma valve implant, Dacryocystectomy, Coil embolization of Dural Sinus Fistula, ICA Aneurysm Repair, Third Molar Extraction Etiology
  7. 7. Spontaneous Retrobulbar Hemorrhage Rare; Largest Report Describes 115 cases over 24 years of Period Orbital Vascular Anomaly : Orbital varix, Lymphangioma Arterio-venous malformation Underlying Systemic Abnormality : Coagulopathy Uncontrolled hypertension Septicemia
  8. 8. Weightlifting, Scuba Diving, Sneezing Other maneuvers that increase venous pressure
  9. 9. Occasionally in sickle cell patients due to orbital bone marrow infarctions May Lead to Subperiosteal Haemorrhage
  10. 10. Post Anaesthetic Retrobulbar Injection Retrobulbar local anesthetic administration can cause bleeding into the buccal fat if the needle extends through the inferior orbital fissure.
  11. 11. Peribulbar Injection
  12. 12. Sub-Tenon ( Episcleral ) Injection
  13. 13. Post-Traumatic A common presumed etiology of post-traumatic vision loss Usually associated with orbital fractures but may occur without a fracture According to two large retrospective series, the incidence of retrobulbar hemorrhage in patients with orbital fractures is 0.45 - 0.6%. R
  14. 14. ( A ) A periorbital hematoma. ( B ) Proptosis ( C ) A coronal CT scan demonstrating an orbital floor fracture and an inferior orbital hematoma. ( D ) A sagittal CT scan demonstrating proptosis, an orbital floor fracture and a subperiosteal hematoma extending to the orbital apex
  15. 15. Anatomy of Orbit Volume of around 30cc Except for numerous small foramina, the bony orbit is a continuous structure, open only anteriorly. Bones contributing to make Orbital Cavity : Frontal, Lacrimal, Ethmoid, Sphenoid Lesser and Greater Wings, Maxilla, Zygoma.
  16. 16. Nerves and Muscles in Orbit
  17. 17. Right Orbit Left Orbit Structures Passing Through The SOF
  18. 18. The Blood Supply
  19. 19. The Major Blood Supply of Orbit The ophthalmic artery contributes maximum The central retinal artery Penetrates the ventral dura to enter the optic nerve approximately 18.6 mm from the optic foramen and 8 mm posterior to the globe. The optic nerve head is supplied by the posterior ciliary arteries.
  20. 20. Anterior and posterior ethmoidal foramina transmit the ethmoidal branches of the ophthalmic artery. The anterior and posterior ethmoidal foramina are located 24 and 36 mm posterior to the anterior lacrimal crest, respectively, along the frontoethmoidal suture The posterior ethmoidal foramen is approximately 6 mm anterior to the optic foramen
  21. 21. A. Opthalmic Artery B. Lacrimal Artery C. Medial Division of Opthalmic artery E. Recurrent Tentorial Branch F. Recurrent Meningeal Branch G. Anterior Ethmoidal artery H. Posterior Ethmoidal artery I. Antero medial branch J. Opthalmic branch of middle mengial artery K. Anterior Deep Temporal Branches of IMAX L. Muscular M. Transosseous N. Inferior Branch of Opthalmic artery O. Distal Inferior Br of IMAX P. Angular br facial art
  22. 22. The Venous Drainage Superior Orbital Vein Inferior Orbital Vein Central Retinal Vein
  23. 23. Soft Tissue Considerations The orbit is lined by periosteum that attaches firmly at the arcus marginalis, foramina, fissures, suture lines and the posterior lacrimal crest. Between these firm attachments the periosteum is loosely adherent, creating a potential space for accumulation of blood The characteristic CT appearance of an acute subperiosteal hematoma is a broad-based extraconal mass that abuts the bony orbit and displaces orbital contents centrally. Radiographically, the mass is high-density, sharply defined, homogeneous and nonenhancing
  24. 24. All mechanisms relate to increased intraorbital pressure and volume: Ischemic optic neuropathy from compression or stretching of the small nutrient vessels Direct compressive optic neuropathy Central retinal artery occlusion Retinal vascular ischemia Resulting In :
  25. 25. The source of bleeding depends upon the inciting event. During blepharoplasty with removal of fat : Bleeding may occur from direct trauma to the vessels of the anterior fat pads, tearing of deep orbital vessels from traction on orbital fat after operations involving the orbital floor, possibly due to damage to the infraorbital artery The orbital perforating branch of the infraorbital artery is rarely mentioned in anatomy texts and is especially susceptible to damage during operations involving the orbital floor. Rubin et al
  26. 26. After endoscopic sinus surgery occurs by violation of the lamina papyracea portion of the ethmoid bone during ethmoidectomy.
  27. 27. Sign and symptoms Massive retrobulbar hemorrhage in the posterior region of the muscle cone, triggered by vessel disruption, leads to progressive exophthalmus with concurrent pupil dilatation, reduced vision and increased intraocular pressure. (Ord 1981; Ord and El Altar 1982) The following are typical signs of an intraorbital hemorrhage with or without orbital fracture (Doden and Schnaudigel 1978):
  28. 28. Livid (cyanotic) swollen eyelids with narrow spontaneous palpebral lid opening, which may be opened actively, though passive opening is only slight
  29. 29. Protrusion of the globe (up to 10 mm) with increasing active and passive immobility
  30. 30. Ischemia of the optic disk and retina with clearly reduced vision or amaurosis Increased intra-ocular pressure more than 80 mmHg
  31. 31. The most common symptoms : pain : Severe and Steady Lancinating Quality pressure, loss of vision, diplopia, nausea and vomiting In addition visual flashes, amaurosis fugax or hemianopsia
  32. 32. Imaging : May be indicated in unusual cases of retrobulbar hemorrhage or in cases associated with trauma. MRI scans provide better visualization of the soft tissues of the orbit Even Ultra Sonography may give an instant Diagnosis Owing to the emergent nature of retrobulbar hemorrhage, imaging studies to confirm the diagnosis are not indicated and will delay treatment
  33. 33. CT scans are preferred because of their fast acquisition time and better visualization of the bony anatomy
  34. 34. Therapeutic Options Once the diagnosis is made, therapy should begin immediately. Optic nerve damage was proportional to the duration of occlusion of CRA Occlusion of 105 min or longer produced irreversible optic nerve damage Occlusion greater that 240 min produced near total optic nerve atrophy Treatment is aimed at lowering intraorbital or intraocular pressure and protecting the optic nerve from damage Rapid surgical intervention remains the mainstay of treatment
  35. 35. Medical Treatment The medical treatments for retrobulbar hemorrhage are controversial. Medical treatment should not delay surgical treatment Medical treatment options include : Oxygen therapy………(95% O2, 5% CO2) may decrease the ischemic insult by dilating intraocular vessels. Mannitol 20% IV ……. The hyperosmotic agent, rapid IV infusion of 1.5 - 2 g/kg over 30 min, with the first 12.5 g over the first 3 min. Acetazolamide …….. The carbonic anhydrase inhibitor, 500 mg IV, Also lowers intraocular pressure
  36. 36. Steroids ……. Methylprednisolone, 100 mg, decrease inflammation and edema and provide some neuroprotection to the optic nerve by stabilizing cell membranes Topical β-blockers ……. Decrease intraocular pressure by lowering aqueous humor secretion. Therapies aimed primarly at reducing intraocular pressure, such as acetazolamide and topical β-blockers, do not address the elevated orbital pressure and do not improve the blood supply to the proximal optic nerve.
  37. 37. Surgical Treatment Postoperative retrobulbar hemorrhage Dressings and sutures should be removed at bedside. The wound opened and explored Decompress the orbit Locate and cauterize the offending bleeding vessel Immediate Postoperative Period Patient should be transported back to the operating room Perform exploration, evacuation of the hematoma and control of hemostasis Late Postoperative Period
  38. 38. Hemorrhage is not postoperative in etiology Relieve orbital compression primarily Can often be achieved via a lateral canthotomy and inferior cantholysis
  39. 39. If further decompression is needed, a lateral anterior orbitotomy may be required to break the fibrous septa of the orbital fat compartments
  40. 40. Pterional orbital decompression Korinth et al. reported a series of 16 cases A neurosurgical approach Removal of the bony lateral and superolateral orbital walls to maximally decompress the orbit Visualize and treat any additional abnormalities, such as focal hematomas or lymphangiomas
  41. 41. The patient must be closely followed with serial examinations Pupillary light reflexes Visual acuity Intraocular pressure Fundoscopy. The head of the bed may be elevated to decrease arterial pressure. The lateral canthotomy and cantholysis may be repaired days later to allow for further drainage in the event of additional hemorrhage or it may be allowed to heal spontaneously
  42. 42. Referrence Books
  43. 43. Thank You