Bilateral Retrobulbar Hemorrhage After Asphyxiation

A 48-year-old woman presented to the emergency department with acute bilateral eye pain, diplopia, and blurry vision. Her examination was notable for reduced supraduction OD, with a diffuse facial petechial rash, significant periorbital ecchymosis, upper eyelid ptosis, and subconjunctival hemorrhage (Fig. 1). The patient’s visual acuity was 20/20 OU without afferent pupillary defect, with normal intraocular pressures and dilated fundus examination. She denied a medical history of coagulopathies, anticoagulant use, or recent periorbital procedures. Further history revealed that the patient had undergone consensual erotic manual strangulation with her partner and suffered immediate loss of consciousness with presenting symptoms after a short period of strangulation. CT scan (Fig. 2A–C) showed bilateral retrobulbar stranding concerning for hemorrhage and right orbital superior extraconal hematoma (black arrow) with mild mass effect on the superior rectus and levator palpebrae superioris, as well as right-sided proptosis with mild straightening of the optic nerve (asterisk). There was no clinical evidence of orbital compartment syndrome, and the decision was made to monitor the patient. On follow-up 4 months after initial injury, the patient reported complete resolution of her pain and double vision, with no persistent cosmetic defects. Retrobulbar hemorrhage is a rare but potentially vision-threatening finding in orbital trauma. Few reports have been published describing retrobulbar hemorrhage after asphyxiation. To our knowledge, this case is the first report of this finding in this setting. Physicians should be aware of this phenomenon to guide workup and management. Patients should also be aware of possible health consequences, including vision-threatening sequelae.FIG 1.FIG 2.