A 13-year-old male presented with headache, decreased vision, and left eye pain following a hair pulling incident at school 5 days prior. CT scans showed progression of a subgaleal hematoma that extended into the left orbit, causing complete ophthalmoplegia and orbital compartment syndrome. The patient underwent emergent canthotomy/cantholysis and anterior orbitotomy with hematoma evacuation. Subgaleal hematomas can extend into the orbit in children due to loosely attached tissues, causing vision loss if not treated urgently.

1. Department of Ophthalmology and Visual Sciences
Sidharth Puri MD, PGY4
August 10, 2018
Grand Rounds
Hair Pulling & Vision Loss

2. CC
Headache, decreased vision and left eye pain
HPI
– 13 yo African American male presenting with
headache 5 days after hair was pulled at school
– Initial CT showed subgaleal hematoma, no orbital
or ocular involvement.
– Returned to ER 2 days later with worsening
headache, new onset left eye pain, and
decreasing vision
Patient Presentation

4. Past Ocular Hx - None
Past Medical Hx- Remote hx of rectal bleeding
age 6 (negative coagulopathy workup)
Past Surgical Hx- None
Fam Hx –Non-contributory
Meds – None
Allergies – None
Social Hx – Student, healthy, lives with family. No
concern for child abuse
History (Hx)

5. • Positive for nausea/vomiting
Review of Systems

6. OD OS
VA 20/20 20/40
Pupils 3 mm No APD 3 mm
IOP 22 mmHg 39 mmHg
EOM Full
Complete restriction
in all gazes
CVF Full Full
External Exam

7. Anterior Segment Exam
PLE OD OS
External/Lids Wnl
Diffuse, boggy fluctuant
mass extending from
crown of head to left
temple and supraorbital
ridge. Proptosis and
tight upper/lower lids.
Conj/Sclera White and quiet
Chemosis, trace
subconjunctival
hemorrhage
Cornea Clear Clear
Ant Chamber Formed Formed
Iris Flat Flat
Lens Clear Clear
Vitreous Clear Clear

9. Posterior Segment Exam
Fundus OD OS
Optic Nerve Pink and sharp Pink and sharp
Macula Flat, good foveal reflex Flat, good foveal reflex
Vessels Normal Caliber Normal Caliber
Periphery Flat, attached 360 Flat, attached 360

10. CT Head Original vs 2 Days Later

11. CT Head Original vs 2 Days Later

12. CT Orbit
Coronal Sagittal

13. • 13 yo male s/p hair-pulling trauma with large
subgaleal hematoma, now with extension into
left superior orbit, resulting in complete
ophthalmoplegia and orbital compartment
syndrome.
• Emergent canthotomy/cantholysis was
performed at bedside
• Patient was taken to OR with Oculoplastics
for emergent left anterior orbitotomy with
hematoma evacuation
Assessment/Plan

15. • Bleeding in potential space between the
thin fibrous galea aponeurotica of the
scalp and the periosteum covering the
cranium
• Occurs in two settings
– Neonates with vacuum-assisted vaginal
delivery
– Childhood traumas (minor and major head
trauma)
Subgaleal Hematomas

16. • Orbital extension is very rare
• In children, galeal aponeurosis is loosely
attached to the pericranium
– Larger quantity of small emissary veins present
compared to adults
• Radial or tangential forces may cause rupture
of these small vessels
• Volume of emissary veins and thinner scalp
in children makes them more susceptible to
collect blood in subgaleal space
Subgaleal Hematomas

18. • Hemorrhage in subgaleal space can
accumulate and dissect to the orbital rim
and extend subperiosteally
– In children, there may be weaker attachments
of periosto-galeal tissue to the bony orbit,
allowing extension of blood
• Prior reports of minor trauma associated
– Hair pulling, hair braiding
Subgaleal Hematomas

19. • Various coagulopathies have been
associated with developing of subgaleal
hematomas
– Factor VII, IX, and XIII
– Need to coordinate with hematology team to
test for these
Coagulopathy Risk?

20. • Subgaleal hematomas are more common in
pediatric populations
• Worsening subgaleal hematoma with
proptosis should raise high suspicion of
orbital extension and stat ophthalmological
evaluation
• Acute intervention with
canthotomy/cantholysis, with possible
surgical evacuation of hematoma, may be
necessary to preserve vision
• Thorough hematologic work-up is necessary
KEY POINTS

21. • Puri S, Duff SM, Mueller B, Prendes M, Clark J.Hairpulling causing vision loss: a case report.
Hamlin H. Subgaleal hematoma caused by hair-pull. JAMA 1968;204:339. Orbit. 2018 May 4:1-4.
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Scalped tomorrow: Massive Subgaleal Haematoma Following Sudden Hair Pulling in an
Adolescent in the Absence of Haematological Abnormality or Skull Fracture. J Craniofac Surg.
2026;27:1261-2
• Karcioglu ZA, Hoehn ME, Lin YP, Walsh J. Ocular involvement after subgaleal hematoma. J
AAPOS. 2008 Oct;12(5):521-3.
• Jenkins TL, Zheng CX, Murchison AP, Bilyk JR. Orbital Compartment Syndrome Following Post-
Traumatic Subgaleal Hematoma. Ophthal Plast Reconstr Surg 33 (2), e33-e36. Mar-Apr 2017
• Chandrasekar, A., Daniela, L., Devia, Y., Julius, Ramachandra, S., Rajendran, A., Sa, G.,
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Manifestation of Mild Hemophilia a in a Child. Sri Ramachandra Journal of Medicine, Jan- June
2015, Vol.8, Issue 1
• Pope-Pegram LD, Hamill MB. . Post-traumatic subgaleal hematoma with subperiosteal orbital
extension. Surv Ophthalmol. 1986 Jan-Feb;30(4):258-62.
• Prakash S. Bilateral proptosis from a subgaleal hematoma. J Neurosurg 1990;72:835.
• Adeloye A, Adeku EL. Subgaleal haematoma in head injuries. Int Surg 1975;60:263
• Vu TT, Guerrera MF, Hamburger EK, et al. Subgaleal hematoma from hair braiding: Case report
and literature review. Pediatr Emerg Care 2004;20:821-3
• Guirgis MF, Segal WA, Lueder GT. Subperiosteal orbital hemorrhage as initial manifestation of
Christmas disease (factor IX deficiency). Am J Ophthalmol 2002;133:584–5.
References

22. • Dr. Clark
Thank You

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