Retrobulbar Haemorrhage or Haematoma

Clinical Description

Bleeding in the retrobulbar space. This may be due to ocular trauma or during retrobulbar injections of drugs or anaesthesia and during sinus surgery. This is rare but sight threatening if not managed urgently

Signs and Symptoms

• History of facial trauma, or periocular interventions
• Proptosis with or without visual impairment
• Severe pain which may be associated with nausea or vomiting

Investigations

• Ultrasonography – visualize the hematoma or active bleeding

TREATMMENT

• Conservative – if mild and minimal risk for vision impairment.
• Admit patient and raise the head of the bed
• Digital ocular massage
• acetazolamide 250-500mg PO/IV STAT then maintenance of 250mg 6 hourly for 3 days to reduce IOP OR mannitol 1-2g/kg IV over 30-60 mins to reduce the volume of the vitreous
• Methylprednisolone 1g IV STAT for neuroprotection
• Consider adjusting any antithrombotic agents the patient may be on – always discuss with the physicians looking after the patient
• Surgical
• Lateral canthotomy and inferior cantholysis 13.14.2.3. CHEMICAL INJURY

Clinical Description

For Chemical injury always treat (see below) and ask questions later. Prognostic features of chemical corneal injuries depend on

• The pH - alkalis are more damaging than acids
• Duration of contact
• Corneal involvement
• Limbal involvement
• Associated nonchemical injury such as thermal injury and blunt trauma
• Conjunctival involvement

Treatment

• Immediate irrigation with water or 2 litres of normal saline until pH is normalized
• Double evert the upper eye lids and remove any retained particulate matter
• Repeat pH after 20 minutes, if abnormal repeat the irrigation
• Daily pH tests, any derangements may indicate the presence of retained chemical particulates and warrants further irrigations and forniceal inspection

Acute management:

• Use preservative free drugs where possible
• Preservative free topical antibiotics e.g.
• Moxifloxacin 0.3% 6 hourly
• Topical cycloplegia e.g. Atropine 1% gutt 12 hourly
• Topical lubricants e.g. Carmellose 1 hourly
• Oral analgesia

Severe Chemical Injuries

• Admit
• Give
• Topical steroids e.g Prednisolone 1% 2- 3 hourly for < 10 days -
• Topical ascorbic acid – Sodium Ascorbate 10% 2 hourly for < 10 days
• Oral Ascorbic Acid 1g every 12hrs
• Systemic Tetracyclines 100mg 24 hourly for 3 months
• Acetazolamide 250mg 6 hourly ± Timolol 0.5% 12 hourly
• Patients need to be counselled for long term follow up to manage complications