new retrobulbar hematoma after third molar extraction: case...

R

mpmuoc

sptaBtmcptd

tavedacd

prat

R

U

D

D

H

e

©

0

d

GOSHTASBY, MIREMADI, AND WARWAR 461

J Oral Maxillofac Surg68:461-464, 2010

Retrobulbar Hematoma After Third MolarExtraction: Case Report and Review

Parviz Goshtasby, MD,* Reza Miremadi, DDS, MD,† and

Ronald Warwar, MD‡

sfitise

eejdameTna

wnac

D

tpcmrmtofesksvhaapodb

eport of a Case

A 19-year-old man was evaluated for extraction of thirdolar teeth. He was healthy with no history of medicalroblems or bleeding disorders, and he was not taking anyedications. The preoperative panoramic radiograph was

nremarkable (Fig 1). He underwent uneventful extractionf all 4 impacted third molar teeth under local and deeponscious sedation.In the immediate postoperative period, while still in the

urgical suite, the patient was noted to have increasing righteriorbital swelling and ecchymosis with evidence of prop-osis and moderate swelling of the right cheek (Figs 2, 3). Inddition, there was a right subconjunctival hemorrhage.allottement of the globes showed slight increased resis-ance to retropulsion on the right. Vision and range ofotion were grossly intact. Given the high clinical suspi-

ion of a retrobulbar hematoma, the decision was made toerform surgical exploration and drainage of any hema-oma. The patient was given a 12-mg dose of intravenousexamethasone before exploration.Upon opening and extending the incision made for ex-

raction of the right maxillary third molar, a moderatemount of blood and hematoma was evacuated. A bleedingessel was identified at the base, which was controlled withlectrocautery followed by packing with HemCon dentalressing (HemCon Medical Technologies, Portland, OR)nd gauze. Once it was confirmed that the bleeding wasontrolled, a Penrose drain was placed to allow dependentrainage, and the patient was taken to the recovery room.Close monitoring and observation were performed. The

atient’s head was kept elevated, and ice was applied to theight periorbital region. Aside from mild periorbital swellingnd ecchymosis, there were no residual deficits. The patienthen underwent an urgent computed tomography (CT)

eceived from the Boonshoft School of Medicine, Wright State

niversity, Dayton, OH.

*Chief Plastic Surgery Resident, Postgraduate Year 9 (PGY-9),

epartment of Plastic and Reconstructive Surgery.

†Clinical Assistant Professor of Oral & Maxillofacial Surgery.

‡Clinical Assistant Professor of Ophthalmology.

Address correspondence and reprint requests to Dr Goshtasby:

epartment of Plastic and Reconstructive Surgery, Miami Valley

ospital, 30 East Apple Street, Suite 2200, Dayton, OH 45409;

-mail: [email protected]

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6802-0036$36.00/0

roi:10.1016/j.joms.2009.07.027

can, which showed a small retrobulbar hematoma con-ned to the extraconal space with minimal impression onhe right lateral rectus muscle (Figs 4, 5). There was nompingement of the optic nerve. Of note, there were noigns of fractures. The patient then underwent an emergentvaluation by an ophthalmologist.The ophthalmologist noted a visual acuity of 20/20 in

ach eye. Pupils, ocular motility, slit lamp, and funduscopyxaminations were all normal, other than a right subcon-unctival hemorrhage. There were no signs of entrapment,iplopia, or strabismus. Intraocular pressures were normalt 13 mm Hg (right) and 15 mm Hg (left). There was noeasurable relative proptosis as indicated by symmetric

xophthalmometric measurements of 18 mm bilaterally.he patient was given oral clindamycin and a methylpred-isolone taper for 1 week for postoperative medical man-gement.

The patient was seen the next day for drain removal andeekly thereafter for 4 weeks. No visual deficits wereoted, and gradual resolution of the right periorbital edemand ecchymosis occurred. The oral wounds healed withoutomplications.

iscussion

Retrobulbar hematomas are medical emergencieshat require prompt diagnosis and management torevent optic nerve ischemia and blindness. The en-losed bony orbital space has little room to accom-odate bleeding, making the optic nerve and central

etinal artery vulnerable to direct compression. Theost common causes reported in the literature are

rauma, reduction of orbital fractures and other peri-rbital surgeries, labor induction, arteriovenous mal-ormations, venous anomalies, ophthalmic artery an-urysm, tumors, hypertension, and blood dyscrasias,uch as hemophilia, von Willebrand disease, and leu-emia.1-16 Among nontraumatic cases, 1 retrospectivetudy of 115 patients noted a 90% incidence of orbitalascular malformations.17 Subperiorbital hematomaas also been described with a lesser frequency afterforceful Valsalva maneuver and migraine head-

ches.18-20 Late onset of retrobulbar hematoma withroptosis has been described 13 to 20 years afterrbital floor fracture repair with alloplastic implantsue to hemorrhage of capillaries surrounding the fi-rous implant capsule.21,22 There has been 1 case

eport occurring after a dental procedure compli-

mailto:[email protected]

ctrt

bnsbocsaaophw

ct

pbssAvapsec

GJ

Fs

GJ

Fs

GJ

F(

462 RETROBULBAR HEMATOMA

ated by postoperative nausea and vomiting withonic seizures.23 To our knowledge, this is the firsteported case of retrobulbar hematoma occurring af-er uncomplicated third molar tooth extraction.

Anatomically, retrobulbar hematomas are classifiedased on their location of occurrence in the intraco-al, extraconal, or subperiosteal space. The intraconalpace is defined as the compartment roughly boundy the 4 rectus muscles, from the anulus of Zinn at therbital apex to their penetration through the Tenonapsule. Injury to the vortex veins, ophthalmic artery,uperior and inferior ophthalmic veins, or muscularrteries can lead to intraconal hemorrhage. Extraconalnd subperiosteal hematomas are due to extraorbitalr orbital bleeding from a number of sources. Ouratient illustrates a case of extraconal retrobulbarematoma, which is supported by the fact that thereas maintenance of vision.The mechanism of the retrobulbar hematoma in this

ase is debatable. One possible explanation would berauma to the maxillary bone incurred during the initial

FIGURE 1. Preoperative panoramic radiograph.

oshtasby, Miremadi, and Warwar. Retrobulbar Hematoma.Oral Maxillofac Surg 2010.

IGURE 2. Frontal view of patient after third molar extractionhowing right periorbital swelling and ecchymosis.


GJ

rocedure. However, the third molar extractions hadeen uneventful without maxillomandibular fractures orignificant time spent on retained root removal. The CTcan confirmed that there was no evidence of fractures.nother possibility is straining with the Valsalva maneu-er, which has been linked to increased intrathoracicnd intra-abdominal pressures, increased jugular venousressure transmitted to the orbit via the valveless venousystem, and rupture of periorbital bridging vessels. How-ver, this also seems unlikely, given that our patient wasomfortable, with stable blood pressure throughout the

IGURE 3. Lateral view of patient after third molar extractionhowing right periorbital swelling and ecchymosis.


IGURE 4. Axial CT scan showing right retrobulbar hematomaarrow).


pwiwoht

bupfvfieoottw

eed9cochep

rpbFovpcnsg

tdtrptopeegrletcasclttl

Frfi

F(

GJ

GOSHTASBY, MIREMADI, AND WARWAR 463

rocedure and postoperatively. Presuming that thereas no trauma to the maxillomandibular region allow-

ng passage of intraoral blood to the periorbital space, asell as no abnormal congenital vascular malformationsr bleeding disorders, the other possibility would beemorrhage draining through a previously unidentifiedract between these 2 spaces.

We hypothesize that uncontrolled bleeding fromranches of the posterior superior alveolar artery afterpper third molar removal may track up through theterygomaxillary fissure into the pterygopalatine

ossa and eventually drain into the retro-orbital spaceia the inferior orbital fissure (Fig 6). The CT scannding of hematoma mostly localized to the inferolat-ral extraconal space near the location of the inferiorrbital fissure would support this mechanism. An-ther possible source of hemorrhage would be injuryo the pterygoid plexus of veins during dental extrac-ion, which could track blood through this same path-ay, leading to a retrobulbar hematoma.Prompt diagnosis and management of this medical

mergency are necessary to prevent optic nerve isch-mia and blindness. Studies suggest that visual lossue to optic nerve ischemia may be irreversible after0 to 120 minutes.24,25 The diagnosis is primarily alinical one, with significant findings including peri-rbital edema, ecchymosis, crepitus, pain, and sub-onjunctival hemorrhage. Other signs include a tense,ard globe; proptosis; ophthalmoplegia; diplopia; affer-nt pupillary defect; and increased resistance to retro-

IGURE 5. Coronal CT scan showing right retrobulbar hematomaarrow).


ulsion. Because cadaveric studies of orbital hemor-GJ

hages have shown that intraocular pressure closelyarallels orbital pressure, intraocular tonometry cane a reliable indicator of elevated orbital pressure.26

unduscopy examination may show a pale optic discr disc edema. Decreased visual acuity and loss ofisual field are ominous signs that may indicate im-ending irreversible blindness. The diagnosis can beonfirmed with ultrasound, CT imaging, or mag-etic resonance imaging.18 However, imaging studieshould not delay the timely treatment of this emer-ency.If there is evidence of loss of vision, severe prop-

osis, limited ocular motility, or an afferent pupillaryefect in the setting of a suspected retrobulbar hema-oma, immediate formal operative drainage of theetro-orbital space would be indicated. Several ap-roaches have been described that serve to effec-ively lower orbital pressure.13 In situations of a post-perative retrobulbar hematoma, such as in ouratient, the existing incision should be opened andxplored to drain and control any hemorrhage. Oth-rwise, a lateral canthotomy and cantholysis affordood exposure to the retro-orbital space with minimalisk of injury to periocular structures.7,27 In brief, theateral canthal region is infiltrated with lidocaine withpinephrine. A straight clamp is used to compress theissue horizontally across the lateral canthus. Thelamp is removed and the skin incised laterally forpproximately 1 cm. The incision dissects throughkin, orbicularis muscle, orbital septum, palpebralonjunctiva, and the Eisler fat pocket. The inferiorimb of the lateral canthal tendon is palpated andransected with the scissors pointed in the inferopos-erior direction. The endpoint is confirmed when theower lid can be easily retracted away from the globe

IGURE 6. Skull model outlining proposed pathway of hemor-hage tracking from pterygomaxillary fissure to inferior orbitalssure via pterygopalatine fossa.


aatcnotrmtdjpiso

ecperbagmdpcbric

eeuurm

R

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

464 RETROBULBAR HEMATOMA

nd lateral orbital rim. If these maneuvers do notdequately alleviate orbital and intraocular pressure,hen an additional inferolateral anterior orbitotomyan be used to aid with decompression.28 This tech-ique entails inferotemporal dissection through therbital fat compartments and fibrous septa betweenhe inferior and lateral rectus muscles. The goal is toeach the retro-orbital space using gentle spreadingovements with a curved, blunt scissor aimed pos-

eromedially behind the globe. Superiorly directedissection should be avoided to minimize risk of in-

ury to the lacrimal gland apparatus and levator pal-ebrae muscle and aponeurosis.7 The lateral canthal

ncision can be repaired at a later date once signs andymptoms have resolved or left open to heal by sec-ndary intention.In cases of a small retrobulbar hematoma without

vidence of impending visual loss, certain maneuversan be used in lieu of or in addition to surgical decom-ression. Medical management includes head-of-bed el-vation and topical ice bags to decrease swelling. Ste-oids such as hydrocortisone and dexamethasone can beeneficial through their anti-inflammatory effects as wells antioxidant effects that decrease production of oxy-en free radical metabolites.29 In addition, the hyperos-olar agent mannitol or dextran can be infused to re-

uce vitreous humor volume and decrease intraocularressure, leading to improved ocular perfusion. Thearbonic anhydrase inhibitor acetazolamide has alsoeen shown to help decrease intraocular pressure byeducing production of aqueous humor.30 Furthermore,t decreases systolic blood pressure, which can helpontrol hemorrhage.In conclusion, retrobulbar hematomas are medical

mergencies that may result from a number of differ-nt causes. We report a unique case that followed theneventful extraction of third molar teeth. Though anncommon occurrence, it is important to be aware ofetrobulbar hemorrhage to allow prompt recognition,anagement, and prevention of visual loss.

eferences1. Jacobsen DM, Itani K, Digre K, et al: Maternal orbital hematoma

associated with labor. Am J Ophthalmol 105:547, 19882. Oruc S, Sener EC, Akman A, et al: Bilateral orbital hemorrhage

induced by labor. Eur J Ophthalmol 11:77, 20013. Krohel GB, Wright JE: Orbital hemorrhage. Am J Ophthalmol

88:254, 1979

4. Law FW: Spontaneous orbital hemorrhage. Br J Ophthalmol

55:556, 1971

5. Geyer O, Wasserman D, Rothkoff L, et al: Orbital haemorrhageinduced by labor. Br J Ophthalmol 74:242, 1990

6. Shimura M, Kiyosawa M, Aikawa H, et al: Spontaneous orbitalhemorrhage in adult females. Ophthalmologica 205:149, 1992

7. Vassallo S, Hartstein M, Howard D, et al: Traumatic retrobulbarhemorrhage: Emergent decompression by lateral canthotomyand cantholysis. J Emerg Med 22:251, 2002

8. Myerson L, Lazar SJ: Intraorbital aneurysm of the ophthalmicartery. Br J Ophthalmol 55:199, 1971

9. Rubenstein RA, Albert DM, Scheie HG: Ocular complications ofhemophilia. Arch Ophthalmol 76:230, 1966

0. Zimmerman A, Merigan TC: Retrobulbar hemorrhage in a he-mophiliac with irreversible loss of vision. Arch Ophthalmol64:949, 1960

1. Reese AB, Guy L: Exophthalmos in leukemia. Am J Ophthalmol16:718, 1933

2. Kubik J: Spontaneous hemorrhage into the orbit in hyperten-sion. Cesk Oftalmol 19:267, 1963

3. Ord RA, El Attar A: Acute retrobulbar hemorrhage complicatinga malar fracture. J Oral Maxillofac Surg 40:234, 1982

4. Rosdeutscher JD, Stadelmann WK: Diagnosis and treatment ofretrobulbar hematoma resulting from blunt periorbital trauma.Ann Plast Surg 41:618, 1998

5. Ares C, Superstein R: Retrobulbar hemorrhage following stra-bismus surgery. J AAPOS 10:594, 2006

6. Moin M, Kersten RC, Bernardini F, et al: Spontaneous hemor-rhage in an intraorbital arteriovenous malformation. Ophthal-mology 107:2215, 2000

7. Sullivan TJ, Wright JE: Non-traumatic orbital hemorrhage. ClinExp Ophthalmol 28:26, 2000

8. Boyer MM, Lucarelli MJ: Valsalva-induced subperiorbital hem-orrhage during migraine. Arch Ophthalmol 116:106, 1998

9. Katz B, Carmody R: Subperiosteal orbital hematoma induced bythe Valsalva maneuver. Am J Ophthalmol 100:617, 1985

0. Katz RS, Abrams G: Orbital subperiosteal hematoma (epiduralhematoma of the orbit). J Clin Neuro Ophthalmol 1:45, 1981

1. Mauriello JA Jr, Flanagan JC, Peyster RG: An unusual late com-plication of orbital floor fracture repair. Ophthalmology 91:102, 1984

2. Gilhotra JS, McNab AA, McKelvie P, et al: Late orbital hemor-rhage around alloplastic orbital floor implants: A case seriesand review. Clin Exp Ophthalmol 30:352, 2002

3. Kue R, Renzi F: Retrobulbar hemorrhage resulting from synco-pal seizures after a dental procedure. Am J Emerg Med 25:228,2007

4. Soll DB: Management of Complications in Ophthalmic PlasticSurgery. Birmingham, AL, Aesculapius Publishing, 1976, p 261

5. Hayreh SS, Kilder HE, Wiengeist TA: Central retinal arteryocclusion and retinal tolerance. Ophthalmology 87:75, 1980

6. Zoumalan CI, Bullock JD, Warwar RE, et al: Evaluation ofintraocular and orbital pressure in the management of orbitalhemorrhage. Arch Ophthalmol 126:1257, 2008

7. Winterton JV, Patel K, Mizen K: Review of management op-tions for a retrobulbar hemorrhage. J Oral Maxillofac Surg65:296, 2007

8. Burkat CN, Lemke BN: Retrobulbar hemorrhage: Inferolateralanterior orbitotomy for emergent management. Arch Ophthal-mol 123:1260, 2005

9. Braughler JM, Hall ED: Effects of multi-dose methylpred-nisolone sodium succinate administration on injured cat spinalcord neurofilament degradation and energy metabolism. J Neu-rosurg 61:290, 1984

0. Castillo GD: Management of blindness in the practice of cos-

metic surgery. Otolaryngol Head Neck Surg 100:559, 1989

Retrobulbar Hematoma After Third Molar Extraction: Case Report and ReviewReport of a CaseDiscussionReferences

new retrobulbar hematoma after third molar extraction: case...

Documents