Retrobulbar Hematoma: Presentation, Management, and Visual Outcomes

Retrobulbar hematoma (RH) is a diagnostic and therapeutic emergency that may cause permanent vision loss. Lateral canthotomy and cantholysis (LCC) is typically performed when IOP is elevated or vision is compromised. The authors describe the outcomes of the largest cohort of patients with RH to date. Patients who presented with acute facial trauma and RH to the R. Adams Cowley Shock Trauma Center (2014-2022) were analyzed to describe their presentation, management, and visual outcomes. In 41 eyes (39 patients) with RH, the most common presenting ocular symptoms and signs were orbital pain [19 (46%)] and subconjunctival hemorrhage [33 (81%)], respectively. LCC was performed in half the cases (n=20). The median (IQR) intraocular pressure (IOP) was significantly higher in the LCC group versus observation: 33 mm Hg (26-44) versus 18 mm Hg (15-21) ( P =0.001). Compared with the observation group, patients treated by LCC were significantly more likely to have no light perception (NLP) vision [0 (0%) versus 6 (50%), P =0.004] and higher IOP [median [IQR] 16 mm Hg (15-21) versus 33 mm Hg (23-44), P =0.001] at presentation. Although 1 of the 6 NLP patients managed by LCC regained some vision, LCC was not associated with significantly different odds of restoration of normal vision [aOR (95% CI) 0.32 (0.04-2.98)]. Visual acuity (VA) at presentation was the only significant predictor of visual acuity after follow-up (B=0.64, P =0.016). LCC is indicated for elevated IOP, as it effectively reduces IOP and improves intraocular perfusion. VA at presentation is the most reliable predictor of VA on follow-up.