Fenestration of Solid Orbital Implants: Reducing Retrobulbar Hematoma Rate

Incidence and management of retrobulbar hemorrhage after blowout fracture repair

BACKGROUND

Retrobulbar hemorrhage (RBH) is a rare complication after orbital surgery but associated with ocular complications including blindness. The aim of this study was to identify clinical characteristics of patients with RBH requiring emergent orbital decompression after blowout fracture repair.

METHOD

A retrospective review of 426 blowout fracture patients at a tertiary oculoplastic clinic provided data regarding demographics, physical examination findings, and computed tomography (CT) images. Extraocular motility had been recorded in patient charts on a scale from 0 to - 4. Patients requiring emergent orbital decompression due to RBH after surgery (RBH group) were compared with those who did not (Control group), using the Mann-Whitney U-test. Incidences of RBH according to primary or secondary surgery were also investigated, using Fisher's exact test.

RESULT

Five (1.2%) of the 426 patients who underwent blowout fracture repair developed RBH requiring emergent intervention. All RBH patients fully recovered after the decompression procedure or conservative treatment. Number of days to surgery was significantly longer in the RBH group (97.0 ± 80.1) than in the Control group (29.0 ± 253.0) (p = 0.05). Preoperative enophthalmos was also significantly greater in the RBH group (RBH vs. Control group, 3.6 ± 1.7 mm versus 1.2 ± 1.3 mm (p = 0.003)). The incidence of RBH was significantly higher in patients that underwent secondary surgery (odds ratio = 92.9 [95% confidence interval, 11.16-773.23], p = 0.001).

CONCLUSIONS

Surgeons should pay more attention to hemostasis and postoperative care in patients with a large preoperative enophthalmic eye, when time from injury to surgery is long and in revision cases. When RBH occurs, time to intervention and surgical decompression is critical for visual recovery and preventing blindness.

TRIAL REGISTRATION

The institutional review board of the Yeungnam University Medical Center approved this study ( YUMC 2018-11-010 ), which was conducted in accord with the Declaration of Helsinki.

Incidence, Risk Factors, and Management of Blindness after Orbital Surgery

PURPOSE

Severe vision loss is a risk of orbital surgery which physicians should counsel patients about, but the overall risk rate is unknown. This research was conducted to determine the risk of severe vision loss related to orbital surgery.

DESIGN

Retrospective review.

PARTICIPANTS

Patients who underwent orbital surgery at either of 2 academic medical centers between January 1994 and December 2014.

METHODS

A billing database search was conducted to identify all patients who had orbital surgery during the study period, cross-checked against diagnostic codes related to vision loss. Charts were screened to determine baseline demographic and medical history, surgical procedure, intraoperative and perioperative management, and visual acuity. Patients with preoperative visual acuity ≥20/200 that worsened ≤20/400 after orbital surgery were included for detailed review. Statistical analysis was conducted to identify factors posing particular risk or benefit to visual outcome in these patients.

MAIN OUTCOME MEASURES

Visual acuity after orbital surgery.

RESULTS

A total of 1665 patients underwent orbital surgery during the inclusion period, with 14 patients sustaining severe vision loss ranging from counting fingers at 1 foot to no light perception (overall risk, 0.84%). The causes of vision loss included retrobulbar hemorrhage, malpositioned implant, optic nerve ischemia, or direct optic nerve insult. When stratified by surgical approach, the risk of a blinding surgical complication was significantly higher for patients undergoing orbital floor repair in the setting of multiple facial fractures (subgroup risk, 6.45%), bony decompression of the optic canal (subgroup risk, 15.6%), or intracranial approach to the orbital roof (subgroup risk, 18.2%). Seven of 8 patients with a potentially reversible cause of postoperative vision loss underwent urgent repeat surgery, and 2 regained substantial vision (20/20 and 20/25). Administration of intravenous corticosteroids had no significant effect on visual acuity outcome.

CONCLUSIONS

The overall risk of severe vision loss after orbital surgery is 0.84%. The subgroup risk is higher in patients undergoing facial polytrauma repair, optic canal decompression, or orbital apex surgery from an intracranial approach. Close postoperative monitoring and urgent assessment and management of acute vision loss may improve visual outcome in some patients.