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J. Nemiroff, S. Baharestani, C. Rosenberg, B. J. Lissauer; Acute Orbital Fracture With Ipsilateral Retrobulbar Hemorrhage: A Review of Cases Presenting to a New York City Trauma Center. Invest. Ophthalmol. Vis. Sci. 2010;51(13):4875.
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To investigate epidemiologic factors, co-morbidities, and the interdisciplinary approach to the evaluation and management of acute orbital fractures (AOF) with ipsilateral retrobulbar hemorrhages that present to a Level I trauma center of a New York City public hospital
We conducted a retrospective review of 14 cases of acute fractures of the orbital wall(s) with concurrent retrobulbar hemorrhages on computed tomography that presented to Bellevue Hospital from July 2007 to June 2009. Medical records were screened for demographic features, associated history, ocular/systemic co-morbidities, and radiographic findings. An IRB exemption was obtained from the Bellevue Research Committee.
Mean age in the study cohort was 48.4 years (Range: 27 - 90) with equal distribution of males and females. Eight cases resulted from blunt trauma, 3 status post fall, 2 after motor vehicle accidents, and 1 from a gun shot wound. Via radiographic review, 21.4% of patients had fractures of only the orbital floor while 7.1% of patients had only either a fracture of the orbital roof, medial wall, or lateral wall, respectively; the remaining 8 patients had fractures of multiple orbital bones. Mean intraocular pressure (IOP) by tonopen in our patients was 21.6 mmHg (Range: 11 - 51). Canthotomy/cantholysis was performed in only 3 patients where either elevated IOP or hemorrhage location were thought to contribute to current or eventual visual compromise. Six patients presented obtunded or after being intubated in the field, and thus could not cooperate with visual acuity measurements or report subjective diplopia. Of the remaining patients, 5 presented with best corrected near visual acuity worse than 20/40 while none reported diplopia. Radiographic evidence of muscle entrapment was present in 14.3% of patients and none demonstrated hemodynamic instability from the oculocardiac reflex. Only 3 patients had asymmetric exophthalmometry measurements greater than 2 mm.
Acute orbital fracture with concurrent retrobulbar hemorrhage requires immediate attention to prevent visual compromise. Although well-described, the diagnosis of retrobulbar hemorrhage in the setting of AOF cannot always be made on elevated IOP and/or orbital asymmetry, alone. Co-management by ophthalmologists with emergency medicine, radiology, neurosurgery, and facial trauma specialists is necessary to optimally care for these patients.
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