Intracranial hemorrhage complicating an orbital decompression

We report a case of intracerebral hemorrhage in the left frontal lobe following a left medial wall orbital decompression for thyroid-related optic neuropathy. There was no obvious fracture in the orbital roof bone but the hemorrhage was felt to occur from a disruption in the orbito-frontal branch of the anterior cerebral artery. The patient was asymptomatic and remained so during the follow-up period.     

Subarachnoid hemorrhage following uneventful thyroid orbital decompression

A 24-year-old woman developed subarachnoid hemorrhage and left frontal lobe ischemia following uneventful right transconjunctival orbital decompression for thyroid-related immune orbitopathy. CT, MRI, CT angiography, and carotid angiography confirmed subarachnoid hemorrhage and brain ischemia on the left side without any cerebral vascular abnormalities on either side. All tests were unremarkable. She fully recovered at last follow-up, 4 months after surgery. We did not find any reason for the subarachnoid hemorrhage and left frontal lobe ischemia. This complication should be considered after orbital surgery for patients with thyroid-related immune orbitopathy.     

Subperiosteal orbital hemorrhage as initial manifestation of Christmas disease (factor IX deficiency)

PURPOSE: To report a case of subperiosteal orbital and subgaleal hemorrhage with optic nerve compromise in a patient with a factor IX deficiency. DESIGN: Interventional case report. METHODS: A 5-year-old male presented 10 days after mild trauma with progressive left-sided scalp swelling, proptosis, and visual loss. RESULTS: The patient had marked proptosis of the left eye, 20/200 visual acuity, and an afferent pupillary defect. Magnetic resonance imaging demonstrated a large subgaleal and left subperiosteal orbital hematoma. Quantitative assays of coagulation proteins identified a factor IX deficiency (Christmas disease). CONCLUSION: Delayed-onset subgaleal and subperiosteal orbital hematoma can rarely be an initial manifestation of Christmas disease.     

Cirrhosis-related Coagulopathy Resulting in Disseminated Intravascular Coagulation and Spontaneous Orbital Hemorrhages

Abstract

A 33-year-old patient presented to our Emergency Department (ED) with left-sided eyelid ecchymoses and edema. A CT scan of the orbits demonstrated a left retrobulbar hemorrhage, prompting an ophthalmology consultation. Upon examination, the patient reported worsening eye pain and decreasing vision in the left eye. Despite aggressive management with superior and inferior lateral canthotomy/cantholysis with placement of an orbital drain, visual loss occurred, and the patient ultimately expired from her systemic condition. Coagulopathy from liver disease resulting in systemic hemorrhage is commonly seen. Orbital hemorrhage in this setting requires emergent diagnosis and management to prevent irreversible compressive optic neuropathy.     

Orbital apex syndrome

A case is presented of a 16-year-old anticoagulated, immunocompromised male presenting with a blind, proptotic left eye, total ophthalmoplegia, and central retinal artery occlusion. Ophthalmic examination revealed other features of the orbital apex syndrome. Mucormycosis misdiagnosed as a traumatic orbital hemorrhage led to the patient's death. In this review, differential diagnosis of the orbital apex syndrome (loss of cranial nerves II, III, IV, ophthalmic division of V, and VI) is outlined, and features, diagnosis, and treatment of mucormycosis are discussed. Although mucormycosis is most commonly seen in diabetics, it should be considered in any immunocompromised patient presenting with the constellation of features of orbital apex syndrome.     

Orbital trauma caused by bicycle hand brakes

PURPOSE: This report aims to increase awareness of an unusual mechanism of orbital injury sustained by bicycle riders. METHODS: In this retrospective small case series, we describe two cases of orbital injury caused by upper eyelid penetration. A 5-year-old boy (patient 1) and a 6-year-old boy (patient 2) presented to our service within a 2-week period. Both had been injured by similarly styled, handlebar-mounted bicycle hand brake levers. Patient 1 had an orbital roof fracture and penetrating brain injury and underwent repair of a left upper eyelid laceration, craniotomy for pseudoencephalocele, and ptosis repair. Patient 2 had orbital hemorrhage and underwent repair of left upper eyelid laceration. RESULTS: In both cases, a handlebar-mounted bicycle hand brake lever perforated the left eyelid when the rider fell onto it. Neither patient was wearing protective headwear or eyewear. Two months after surgery, patient 1 had 20/25 visual acuity OU and excellent cosmetic appearance. Patient 2 had baseline amblyopic vision 2 days after surgery but moved from town and was lost to follow-up. CONCLUSIONS: Orbit injuries from bicycle brake levers are rare, and helmets or protective eyewear probably would not have prevented these injuries. However, a change in the design and/or mounting location of handlebar-mounted brake levers might help prevent further injuries of this type.     

自发性眼眶出血致视力丧失

目的 通过对自发性眼眶出血导致视力丧失的临床及影像学分析，探讨视力丧失的发生机理、视力丧失的相关因素，以及眼眶出血后的治疗方法．方法 对我院２０年间收治的自发性眼眶出血导致视力丧失２０例患者临床表现、影像学特征和治疗方法进行分析。结果 自发性眼眶出血导致视力丧失的发生率约为２０％，视力丧失的相关因素包括就诊及治疗是否及时、治疗方法是否得当、出血的部位和出血量的多少。治疗原则为及时引流眶内出血或手术     

Hairpulling causing vision loss: a case report

Subperiosteal extension of a subgaleal hematoma (SGH) to the orbit is a reported, but rare complication of trauma. This report details a 13-year-old African-American male who originally presented to the emergency department after trauma with headache and was found on CT imaging to have a contained subgaleal hemorrhage. He presented 2 days later with increased pain and proptosis of the left eye with findings of decreased visual acuity, elevated intraocular pressure, proptosis, and complete external ophthalmoplegia. Repeat imaging revealed enlargement of the SGH with subperiosteal extension into the left orbit. He required an emergent lateral canthotomy with inferior and superior cantholysis, followed by surgical drainage of the subperiosteal and SGH. Hematologic workup for coagulopathy was negative. The authors urge point-of-care providers to consider ophthalmic evaluation for patients with large SGHs where orbital extension and vision loss may occur. Furthermore, SGH causing orbital compartment syndrome may develop in patients who have normal blood work and clotting factors.     

Warfarin-associated delayed orbital hemorrhage after orbital fracture repair with smooth nylon foil implant

The authors describe the first report in the literature of delayed orbital hemorrhage that may be partly caused by supratherapeutic anticoagulation. A 52-year-old man with supratherapeutic international normalized ratio (INR) presented with acute proptosis, orbital pain and diplopia 9 months after the floor and medial orbital wall fracture repair using nylon foil implant. He was found to have hemorrhaged into the capsule surrounding the orbital implant. Three weeks later, the patient underwent implant removal after warfarin was discontinued for 5 days and INR was normalized. His symptoms resolved postoperatively. This case describes a unique risk factor of delayed orbital hemorrhage in patients with previous orbital fracture repair, and highlights that coagulopathy should be investigated in patients presenting with acute proptosis with a history of orbital fracture repair. The authors also provide a comprehensive and up-to-date literature review on previously reported cases with delayed hemorrhagic complications from alloplastic orbital implants.     

Bilateral orbital hemorrhage in a newborn

PURPOSE: To report a case of severe bilateral proptosis resulting from orbital hemorrhage in a newborn and to discuss the differential diagnoses and management. METHOD: Case report of a 13-day-old male infant with bilateral proptosis since birth. The proptosis was monitored with clinical examinations and computed tomography as well as magnetic resonance imaging (MRI) scans, and it was managed with antibiotic ointment and patching. The MRI scans demonstrated bilateral subperiosteal orbital hemorrhage. RESULTS: Proptosis decreased, and there was successful, complete recovery without untoward sequelae in 14 days; follow-up indicated no late complications at age 1 year. CONCLUSION: Spontaneous orbital hemorrhage, unilateral or bilateral, is uncommon in an otherwise healthy newborn without apparent history of birth trauma. Magnetic resonance imaging scans are helpful in making the diagnosis of subperiosteal hemorrhage, and conservative management is advised.     

Nontraumatic orbital hemorrhage

Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, “encysted” hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome.     

Spontaneous orbital and periocular hemorrhage in a patient with epithelioid hemangioma

Epithelioid hemangioma, or angiolymphoid hyperplasia with eosinophilia, is a benign vascular lesion that infrequently involves the orbit. We report a case of spontaneous orbital and periocular hemorrhage in a patient with epithelioid hemangioma of the orbit. Ophthalmic examination was accompanied by CT and MRI, followed by histopathologic diagnosis. The patient presented with headache, eyelid bruising, and double vision. Ophthalmic examination showed ecchymosis, proptosis, and limited extraocular movements of the affected eye. Imaging studies showed a cystic right orbital mass. Histologic examination showed plump endothelial cells accompanied by lymphocytes, plasma cells, and eosinophils. A diagnosis of epithelioid hemangioma was rendered. To our knowledge, this is the first reported case of spontaneous orbital and periocular hemorrhage associated with epithelioid hemangioma. Epithelioid hemangioma should be considered in the differential diagnosis for patients presenting with spontaneous orbital or periocular hemorrhage.     

以自发性出血为特征的眼眶静脉畸形临床分析

目的 探讨眼眶静脉畸形伴自发性出血的临床、影像学特征、诊断和治疗原则.方法 对15例单眼眼眶静脉畸形伴自发性出血的病例进行回顾性分析.结果 所有患者中,除1例Valsalva试验出现眼球突出度增加外,余均无扩张性病变临床征象.15例患者均行眼眶CT检查,6例误诊为肿瘤,其中5例均经MRI明确为出血.7例行保守治疗,出血吸收后,影像学随访发现扩张性静脉畸形.8例行手术治疗,2例病理提示为混合型静脉淋巴管瘤,6例为静脉性血管畸形,术后6例视力获得提高.结论 与全身静脉系统联系较少的眼眶静脉畸形,临床上常无特征性表现,一旦发生眶内出血易误诊为肿瘤.对不明原因的急性眼球突出伴眼眶胀痛,眼眶MRI常可发现出血性病变,无明显视力下降时可予保守治疗,待出血吸收后影像学随访检查常可发现扩张畸形的血管病变.视力显著下降的患者,应行手术干预,多可获得视力恢复.

Abstract：

Objective To approach the clinical and image features,diagnosis and treatment of orbital venous malformations(OVMs)presenting with spontaneous hemorrhage.Methods A retrospective review of 15 patients with OVMS presenting with spontaneous hemorrhage.Results None of all the patients showed clinically distensibility except 1 observed worsening proptosis with Valsalva maneuver.CT scan were done in all patients.6 were referred with a suspicion of orbital tumor,5 of them were identified orbital hemorrhage by typical findings on MRI.7 patients were treated conservatively.After resolution of the hemorrhage,they evidenced a distensible OVMs in a follow-up imaging study.8 patients were treated by surgical excision and were all examined histopathologically.2 of them were confirmed venous-lymphatic malformations,6 were confirmed OVMs.Visual acuity was improved in 6 patients.Conclusions OVMs with small venous connection may be not clinically evident.Spontaneous hemorrhage develops in this lesion can simulate orbital tumors.In cases that show acute exophthalmos and ocular pain,MRI should be used to verify the hemorrhage.It is better to wait,with conservative treatment when one without visual deterioration,until the hemorrhage is resolved and then performed a follow-up CT for the diagnosis.Surgical intervention should be confirmed to those with visual deterioratinn.Most of them can get visual recovery.     

Optic nerve avulsion from a golfing injury

PURPOSE: To describe a patient with optic nerve avulsion after being struck in the eye with a golf club. METHODS: A 10-year-old male was hit in the left eye by a golf club. The patient underwent full ophthalmoscopic evaluation and neuroimaging. RESULTS: The patient had no light perception in the left eye when first seen. Avulsion of the optic nerve with vitreous hemorrhage was apparent on examination. Computed tomographic imaging of the brain and orbits revealed no abnormalities. CONCLUSIONS: Optic nerve avulsion from golf-related injury is more likely to occur when the impact site is between the globe and the orbital rim. Rupture of the globe is more likely to occur with direct impact to it.     

Smooth nylon foil (SupraFOIL) orbital implants in orbital fractures: a case series of 181 patients

PURPOSE: The SupraFOIL smooth nylon foil implant is a polyamide sheet available in varying thicknesses that has been used in orbital reconstruction following trauma. The authors report their experience with smooth nylon foil implants in the repair of orbital fractures. METHODS: A retrospective chart review of patients having undergone repair of orbital fractures between January 1, 1995 and December 31, 2003 was conducted. The Wilcoxon test was used to compare cases with complications and those with no complications. RESULTS: Of 282 orbits that underwent fracture repair with alloplastic material, 87 were excluded because non-nylon foil implants were used alone or in combination with nylon foil to repair the orbital fracture. An additional 14 fractures were excluded because of insufficient clinical data or lack of follow-up, for a total of 181 orbits that underwent orbital fracture repair with only nylon foil. A transconjunctival approach was used in 98% cases, and all 181 implants were fixated with at least 1 titanium screw. Average follow-up was 362.8 days. The overall complication rate was 1.7%. One patient had an acute postoperative orbital hemorrhage (0.6% acute complication rate). Two patients had late orbital infections, 683 days and 984 days following repair (1.1% late complication rate). CONCLUSIONS: The authors found the smooth nylon foil implant to be safe and effective in orbital fracture repair. The lower rate of complications the authors observed compared with previously reported series may be related to implant fixation. A titanium screw secured just posterior to the orbital rim may decrease long-term complications by providing more stability than implants left without fixation.     

Orbital varix rupture during cataract surgery

We report a case of orbital varix rupture during cataract surgery with retrobulbar anesthesia. No remarkable changes were observed 10 minutes after retrobulbar anesthesia was administered, but a rise in intraocular and intraorbital pressure was noted about 10 minutes after phacoemulsification began. The eyelid could not be closed at the end of surgery because of severe proptosis. Follow-up by magnetic resonance imaging and color Doppler imaging revealed orbital hemorrhage and varix. Based on the time of its appearance, the hemorrhage was thought to be the result of venous congestion caused by anesthetic agent in the muscle cone. Although intermittent exophthalmos is a symptom of orbital varix, silent orbital varix should be considered when selecting the method of anesthesia for ocular surgery.     

Renal medullary carcinoma metastatic to the orbit: a clinicopathologic report

A 39-year-old black man with sickle cell trait presented with a rapidly progressive, painful proptosis of the left eye. A computed tomographic scan was interpreted as revealing a cavernous hemangioma. Medial orbitotomy revealed a hard, gray mass supranasal to the optic nerve and invading the medial rectus muscle. Intraoperative frozen section specimens were read initially by the pathologist as metastatic adenocarcinoma. On gross examination, the conspicuous hemorrhage, necrosis, and bright yellow color characteristic of renal cell carcinoma were not present. Final pathologic analysis of the orbital lesion revealed metastatic renal medullary cell carcinoma. The primary lesion was located in the right kidney. Renal medullary carcinoma is a rare tumor, often affecting young individuals with sickle cell trait or disease. We report the first confirmed case of renal medullary carcinoma metastatic to the orbit with orbital symptoms preceding the diagnosis of the primary tumor.     

Mastication Induced Retrobulbar Hemorrhage

Abstract

Retrobulbar hemorrhage is a feared potentially sight threatening complication after orbital decompression surgery. We present a patient, 36 hours after surgery, while forcefully biting, suddenly developed a retrobulbar hemorrhage arising from the temporalis muscle causing an orbital compartment syndrome. Rapid intervention with canthotomy and cantholysis was associated with recovery of vision from absent light perception to 20/20. A mastication induced retrobulbar hemorrhage has not been previously described.     

外伤性眶内血肿的临床表现及治疗

目的 探讨外伤性眶内血肿的临床特点和治疗方法。方法 回顾分析23例23眼外伤性眶内血肿的临床表现，探讨了外伤性眶内血肿的发病原因、影像学特征和治疗方法。结果 外伤性眶内血肿引起视力下降、眼眶压增高、眼球突出、复视及眼部运动神经损害。视力恢复较血肿消退快。血肿消退速度从2周后加快。视力恢复≥0．3者19眼占82．61％，眼运动神经损伤恢复者18例占78．26％。结论 外伤性眶内血肿对眼组织损害较大，应早期采取综合治疗：溶解血肿、降低眶压、促进吸收并改善循环。     

Spontaneous subperiosteal orbital hemorrhage following thrombolytic therapy for myocardial infarction

A 60-year-old man experienced right orbital pain, periorbital swelling, and double vision 2 hours after treatment with streptokinase and heparin for myocardial infarction. Orbital CT revealed a right superior subperiosteal orbital hemorrhage. Conservative management in the absence of visual compromise was sufficient, as his symptoms and signs resolved completely in approximately 6 weeks with no recurrence during 6 months of follow-up. This case demonstrates that nontraumatic subperiosteal orbital hemorrhage may occur after thrombolytic therapy for myocardial infarction. Conservative treatment with cold compresses in the absence of visual impairment may be sufficient, as was in our patient and others.