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A. M. Ramirez, C. L. Fry, L. D. Walker; Retrobulbar Hemorrhage After Blunt Trauma: A Case Series. Invest. Ophthalmol. Vis. Sci. 2009;50(13):5327.
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The purpose of this study is to identify the level of intraocular pressure that leads to vision loss from retrobulbar hemorrhage (RBH) after blunt trauma.
Twenty-seven consecutive cases of RBH were reviewed. Parameters assessed included vision, afferent pupillary defect (APD), intraocular pressure (IOP), surgical intervention and outcome. The subject population included female and male patients of all ages with RBH after trauma. Retrobulbar hemorrhage secondary to injections and atraumatic mechanisms were excluded.
Twenty-seven cases with RBH were reviewed. Six eyes had no recorded visual acuity secondary to intubation upon presentation. Of the remaining twenty-one eyes, 5% (one eye) were No Light Perception (NLP), 33% (7 eyes) had visual acuity (VA) ranging from 20/200 to Counting Fingers (CF), 10% (2 eyes) were 20/50, 52% (11 eyes) had VA>20/25. The average IOP was 28 mm Hg, with 46% (12 eyes) having IOP<22, 35% (9 eyes) with IOP 23-30, and 19% (5 eyes) with IOP>34 mm Hg. Four of 26 eyes had an APD. Five of 27 eyes were treated with canthotomy and cantholysis and all had VA<20/400; four patients treated had an APD, 3/5 eyes (60%) had an IOP < 27mmHg with an average difference between affected and unaffected eyes of 9.3 mm Hg, and 2/5 (40%) had an IOP>40 mmHg. Of the eyes with RBH and vision better than 20/30, the average difference in IOP between affected and unaffected eyes was 5.5 mm Hg. Final average VA of treated patients, in whom follow-up was available, was 20/25-20/30.
Retrobulbar hemorrhages can result in severe visual loss. Traditionally, it has been thought that a canthotomy and cantholysis are necessary when the intraocular pressure is greater than 40 mmHg to prevent vision loss. This case series demonstrates that of the five cases requiring surgical intervention for compromised vision, 60% had an IOP lower than 27 mmHg with an average asymmetry between affected and unaffected eyes of 9.3 mm Hg. These cases demonstrate the importance of assessing the patients with RBH for signs of compromised vision and optic neuropathy, and the value in comparing intraocular pressures between the affected and unaffected eyes. As a result of our findings a lower threshold IOP for intervention should be contemplated. By releasing the orbital pressure with simple bedside procedures performed emergently, vision may be significantly improved or restored.
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