ORIGINAL ARTICLE

Orbital Hematoma Caused by Bleeding From Orbital Branch of the Infraorbital Artery After Reconstruction of an Orbital Fracture Kun Hwang, MD, PhD,* Joo Ho Kim, MD,* and Young Hye Kang, MDÞ Abstract: We experienced and report on a case of retrobulbar hematoma caused by bleeding from the orbital branch of the infraorbital artery after a medial orbital wall reconstruction. A healthy 28-year-old man struck his left eye while playing baseball before admission. A computed tomographic scan revealed an approximately 13  12-mmYsized fracture of the left orbit medial wall. The medial orbit wall was reconstructed through a subciliary approach on the 18th day after the injury. Approximately 15 hours after the orbit wall reconstruction, the patient complained of pain in the left orbital area, headache, and vomiting. Upon an examination, swelling and ecchymosis were observed on the left eye. His visual acuity was 0.8 (oculus dexter [OD])/0.4 (oculus sinister [OS]) and the intraocular pressure was 18 (OD)/24 (OS) mm Hg by a Goldmann applanation tonometry. A computed tomographic scan showed an intraorbital hematoma and proptosis on the left side. In an emergency operation, a hematoma with a volume of approximately 2 to 3 mL was evacuated and an active bleeding point was noted on the orbital floor, which was thought to be the orbital branch of the infraorbital nerve. The bleeding point was cauterized. After the operation, his visual acuity was 1.0 (OD)/0.8 (OS) and the ocular pressure normalized to 16 (OD)/16 (OS) mm Hg by a Goldmann applanation tonometry. Close observation and meticulous hemostasis along the infraorbital groove may be needed in an orbital floor exploration to prevent postoperative orbital hematoma.

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etrobulbar hematomas are rare complications after orbital surgery, with the potentially disastrous consequence of visual impairment and blindness after facial bone reconstruction.1,2 A retrobulbar hematoma seems to result from bleeding caused by damage to the zygomaticotemporal vessels, posterior ethmoidal vessels, and vessels accompanying the infraorbital nerve.3 We experienced and report on a case of retrobulbar hematoma caused by bleeding from the orbital branch of the infraorbital artery after a medial orbital wall reconstruction.

PATIENT A healthy 28-year-old man struck his left eye while playing baseball before admission. His visual acuity was 1.0 (OD)/0.4 (OS) and the intraocular pressure was 13 (oculus dexter [OD])/ 14 (oculus sinister [OS]) mm Hg. A computed tomographic (CT) scan revealed an approximately 13  12-mmYsized fracture of the left orbit medial wall (Fig. 1). There was also a 2-mm enophthalmos on his left eye. Medial orbit wall was reconstructed through a subciliary approach on the 18th day after the injury.4 A poly L-lactic, D-lactic acid resorbable sheet (Inion, Tampere, Finland) was inserted and fixed. The visual acuity and light reflex in both eyes were normal after the surgery. Approximately 15 hours after the orbit wall reconstruction, the patient complained of pain in the left orbital area, headache, and

Key Words: Hematoma, orbital fractures, maxillary artery (J Craniofac Surg 2014;25: 375Y376)

What Is This Box? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code links to the online version of the article. FIGURE 1. Preoperative CT scan, coronal view. Fracture of the left orbit medial wall is shown.

From the *Department of Plastic Surgery, Inha University School of Medicine, and †Department of Radiology, Inha University Hospital, Incheon, South Korea. Received October 30, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Dr. Kun Hwang, Department of Plastic Surgery, Inha University School of Medicine, 27 Inhang-ro, Jung-gu, Incheon, 400-711, South Korea; E-mail: [email protected] Supported by a grant from Inha University (Inha research grant). The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000637

The Journal of Craniofacial Surgery

FIGURE 2. Swelling and ecchymosis on the left orbital area.

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Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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FIGURE 3. Emergency CT scan. Left, Axial view. Right, Coronal view. The CT scan shows an intraorbital hematoma (asterisk) and proptosis on the left side; however, the fat layer (arrowheads) is intact between the hematoma and extraocular muscles.

vomiting. On examination, swelling and ecchymosis were observed on the left eye (Fig. 2). His visual acuity was 0.8 (OD)/0.4 (OS) and intraocular pressure was 18 (OD)/24 (OS) mm Hg by a Goldmann applanation tonometry. A 10-mg prednisolone was given per OS. A CT scan showed an intraorbital hematoma and proptosis on the left side (Fig. 3). Emergency surgery was performed. A hematoma with a volume of approximately 2 to 3 mL was evacuated and an active bleeding point was noted on the orbital floor, which was thought to be the orbital branch of the infraorbital nerve. The bleeding point was cauterized with hemostatic forceps during the exploration (Fig. 4). A silicone drain was inserted and the wound was closed. After operation, his visual acuity was 1.0 (OD)/0.8 (OS) and ocular pressure normalized to 16 (OD)/16 (OS) mm Hg by a Goldmann applanation tonometry. The pain was reduced and the vision improved after the surgery. Stitches were removed on the fifth day after the reoperation, and the patient was discharged on the seventh day.

DISCUSSION Retrobulbar hematomas occur after the reduction of fractured orbital walls with a reported incidence of 0.3%.5 Rosdeutscher and Stadelmann,3 in their cadaver dissection, demonstrated the possible source of bleeding that can cause retrobulbar hematoma in a blunt periorbital trauma: zygomaticotemporal vessels, posterior ethmoidal vessels, and vessels accompanying the infraorbital nerve. Cheon et al1 assumed that retrobulbar hematomas result from bleeding caused by damage to the infraorbital arteries or the anterior and posterior ethmoidal arteries during surgery and rebound vasodilation of the vascular puncture site upon injection. In our previous article, we illustrated the orbital branches of infraorbital arteries during orbital floor exploration. If the globe is retracted upward, orbital branches of the infraorbital artery can be

FIGURE 4. Intraoperative photographs. Left, Two- to 3-mL of hematoma is seen. Right, Bleeding point (arrowhead) was cauterized.

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FIGURE 5. Drawing of the orbital branches of the infraorbital artery. Left, In resting position. Right, During orbital floor exploration, if the globe is retracted upward, orbital branches of the infraorbital artery (arrow) can be identified at the infraorbital groove. Arrowhead indicates the infraorbital nerve. The images were reproduced from the study of Hwang and Hwang.6 Adaptations are themselves works protected by copyright. So in order to publish this adaptation, authorization must be obtained both from the owner of the copyright in the original work and from the owner of copyright in the translation or adaptation.

identified at the infraorbital groove (Fig. 5).6 In the current study, an active bleeding point was noted on the orbital floor, which was thought to be the orbital branch of the infraorbital nerve. Lisman et al7 stated that tractional pressure on the posterior orbital vessels during fat excision is thought to generate bleeding distal to the surgical field. Liu8 wrote that retrobulbar hemorrhages are most likely to occur if there is excessive or rigorous manipulation of the orbital tissues or poor hemostasis. In retrospect, we did not perform a meticulous bleeding control because we did not observe active bleeding during the orbital wall reconstruction. In the emergency surgery, an active bleeding point was noted on the orbital floor, which was thought to be the orbital branch of the infraorbital nerve. Close observation and meticulous hemostasis along the infraorbital groove may be needed in orbital floor exploration. We could prevent this by performing immediate decompression after a definite diagnosis. The initial presentation of the patient was eye pain with vomiting. The intraorbital hematoma was confirmed through computed tomography, and immediate medical and surgical treatments were instituted.

REFERENCES 1. Cheon JS, Seo BN, Yang JY, et al. Retrobulbar hematoma in blow-out fracture after open reduction. Arch Plast Surg 2013l;40:445Y449 2. Chen CH, Chen CT, Huang F. Retrobulbar hematoma as a rare complication after secondary correction of enophthalmos. J Craniofac Surg 2009;20:963Y967 3. Rosdeutscher JD, Stadelmann WK. Diagnosis and treatment of retrobulbar hematoma resulting from blunt periorbital trauma. Ann Plast Surg 1998;41:618Y622 4. Hwang K. Medial orbital wall reconstruction through subciliary approach: revisited. J Craniofac Surg 2009;20:1280Y1282 5. Ord RA. Post-operative retrobulbar haemorrhage and blindness complicating trauma surgery. Br J Oral Surg 1981;19:202Y207 6. Hwang K, Hwang JH. Do we have to dissect infraorbital nerve from periorbita in orbital floor fracture? J Craniofac Surg 2009;20:1260Y1262 7. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin Plast Surg 1988;15:309Y335 8. Liu D. Blindness after blow-out fracture repair. Ophthal Plast Reconstr Surg 1994;10:206Y210

* 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Orbital hematoma caused by bleeding from orbital branch of the infraorbital artery after reconstruction of an orbital fracture.

We experienced and report on a case of retrobulbar hematoma caused by bleeding from the orbital branch of the infraorbital artery after a medial orbit...
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