Retrobulbar hematoma in oral and maxillofacial trauma: an emergency requiring prompt recognition

To the Editor, Retrobulbar hematoma (RBH) is significantly associated with hypertension, the use of anticoagulants, and Valsalva maneuvers; the risk is further heightened by retrobulbar anesthesia. RBH can result in midface fractures, zygomaticomaxillary complex injuries, or orbital floor fractures. Bleeding from these injuries can immediately raise the pressure inside the eye[1]. Retrospective studies may ignore narratives or physical tests in OMF trauma cases, where concurrent facial fractures can hide first indications of RBH, needing a full ocular examination. Findings include fractures of the orbital wall, visual abnormalities, and head trauma which are connected to an increased chance of serious eye and surrounding tissue injuries. Hence, these circumstances show the significance of complete ophthalmologic screening in OMF trauma patients to avoid visual impairment and increase recovery[2]. If there is sudden bleeding behind the eye, then intraorbital pressure can rapidly increase, potentially leading to orbital compartment syndrome, decreased arterial flow, and venous pooling. Permanent vision loss may result if intraocular pressure stays high for 60 to 100 minutes. Moreover, standard treatments include lowering intraocular pressure and decompressing the optic nerve (by cantholysis or canthotomy). Apart from that, more accurate decompression, such as orbital septum release, may be a choice depending on clinical scenarios. This approach is advocated by recent data demonstrating favorable visual recovery when timely decompression is performed, even in some cases where surgery occurred beyond the traditionally recommended 2-h window[3]. Symptoms of RBH can comprise proptosis, periorbital bruises, pain, impaired vision, and symptoms of pressure around the globe that might match those found in traumas. Identification is done through computed tomography (CT) or, if accessible, bedside point-of-care ultrasound (POCUS) provides diagnosis, particularly in emergency contexts, with limited resources[4]. Maxillofacial surgeons addressing midface/orbital fractures must stay watchful. Following closure of orbital-wall fractures, RBH, albeit rare, is a reported complication. In a case series, one patient experienced lifelong vision loss; another has corrected vision following rapid decompression, while a third one recovered without sequelae. This highlights the importance of prompt postoperative surveillance for RBH in patients undergoing OMF surgery[5]. If OMF trauma perspectives are incorporated, such as comorbidity assessment, proactive ophthalmic evaluation, and readiness for emergency decompression, then they can reinforce clinical practice. Also, this will help prevent irreversible vision loss in facial‑trauma patients. This letter to the editor adheres to the Transparency in the Reporting of Artificial Intelligence in Research (TITAN) guideline[6].