Unilateral retrobulbar haemorrhage in a cat secondary to suspected anticoagulant rodenticide intoxication.

A 6-month-old intact female mixed-breed kitten presented with severe exophthalmos of the left eye. Periocular lesions, including subconjunctival haemorrhage, third eyelid protrusion, and left eyelid oedema, were detected in the absence of globe retropulsion. The left intraocular pressure was increased, and ocular ultrasonography revealed ipsilateral retrobulbar fluid. Coagulation panels were markedly prolonged and severe anaemia was detected. Ultrasound-guided retrobulbar centesis performed to decrease intraocular pressure yielded blood. Based on the history and clinical findings, anticoagulant rodenticide intoxication was suspected. Treatment included partial tarsorrhaphy and the administration of topical antibiotics, artificial tears, and vitamin K1. Fresh whole blood and fresh frozen plasma were transfused for supportive therapy. Coagulation parameters improved after 7 days of hospitalisation. The periocular lesions resolved within 14 days, despite persistent optic nerve damage and blindness. This case report raises the possibility that anticoagulant rodenticide toxicity may result in retrobulbar haemorrhage in the absence of other typical cavitary bleeding. Although uncommon, anticoagulant rodenticide toxicity should be considered in cats with retrobulbar haemorrhage.

Warfarin-associated delayed orbital hemorrhage after orbital fracture repair with smooth nylon foil implant.

The authors describe the first report in the literature of delayed orbital hemorrhage that may be partly caused by supratherapeutic anticoagulation. A 52-year-old man with supratherapeutic international normalized ratio (INR) presented with acute proptosis, orbital pain and diplopia 9 months after the floor and medial orbital wall fracture repair using nylon foil implant. He was found to have hemorrhaged into the capsule surrounding the orbital implant. Three weeks later, the patient underwent implant removal after warfarin was discontinued for 5 days and INR was normalized. His symptoms resolved postoperatively. This case describes a unique risk factor of delayed orbital hemorrhage in patients with previous orbital fracture repair, and highlights that coagulopathy should be investigated in patients presenting with acute proptosis with a history of orbital fracture repair. The authors also provide a comprehensive and up-to-date literature review on previously reported cases with delayed hemorrhagic complications from alloplastic orbital implants.

A Case of a Spontaneous Self-resolving Retrobulbar Hemorrhage Following 3,4-Methylenedioxy-methamphetamine Use.

This case report discusses the case of a 23-year-old male patient who experienced retrobulbar pain, diplopia, proptosis, and mild lower eyelid bruising after consuming 3,4-methylenedioxy-methamphetamine. The symptoms settled over 10 days and vision returned to normal without intervention. The authors discuss the differential diagnosis relevant to the presenting complaints and propose several mechanisms linking 3,4-methylenedioxy-methamphetamine use to spontaneous nontraumatic intraorbital hematoma.

Unilateral retrobulbar hematoma following maxillary nerve block in a dog.

OBJECTIVE: To describe the clinical findings and management of a case of retrobulbar hematoma formation secondary to performance of a maxillary nerve block in a dog. CASE SUMMARY: An 11-year-old dog was presented for a routine dental procedure including dental extraction to be performed under general anesthesia. After premedication with intramuscular methadone, anesthesia was induced with intravenous alfaxalone until depth of anesthesia was sufficient to allow orotracheal intubation. Anesthesia was maintained with isoflurane delivered in 100% oxygen. A bilateral maxillary nerve block was performed. During administration of the left nerve block, blood was aspirated. Twenty minutes after placement of the left maxillary nerve block, exophthalmos, periorbital swelling, extensive scleral hemorrhage, and ecchymosis with a 2 × 2 cm region of moderate swelling on the palatal mucosa around the injection site were noted. These lesions were the result of retrobulbar hematoma formation following vessel puncture. Treatment included immediate creation of a drainage tract and administration of anti-inflammatories (carprofen 2 mg/kg PO q 12 h for 7 days), broad spectrum antimicrobial therapy (cefovicin 8 mg/kg SC once), and eye drops (viscotears, 2 drops OS q 12 h for 7 days). The periorbital swelling was significantly reduced within 1 hour of drainage and had almost completely resolved 1 week later. NEW OR UNIQUE INFORMATION PROVIDED: This clinical report details the development and successful management of a unilateral retrobulbar hemorrhage following maxillary nerve block. Management of this condition requires prompt recognition and treatment to prevent permanent damage to the eye. The cornerstone of treatment is drainage, which rapidly decreases the increased intraorbital and intraocular pressure. To our knowledge, this is the first documentation of this complication in the English language literature.

Hyaluronidase hypersensitivity: A rare complication of peribulbar block.

Peribulbar block, though safe, can cause serious complications such as globe perforation and peribulbar hemorrhage. Hyaluronidase is an enzyme that is used as an adjuvant in peribulbar anesthesia, and it helps in rapid penetration of the anesthetic agent. Hypersensitivity to hyaluronidase is a rare but potentially sight-threatening complication. We report a case of hyaluronidase hypersensitivity following peribulbar injection for cataract surgery mimicking as peribulbar hematoma in the immediate postinjection phase and as orbital cellulitis 48 h later.

Dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia.

PURPOSE: To evaluate the prevalence of dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia. SETTING: Department of Ophthalmology, Ludwig-Maximilans Universität, München, Germany. DESIGN: Retrospective study. METHODS: Two groups of patients were screened retrospectively over a 5-year period for the inclusion criterion of severe retrobulbar hematoma after retrobulbar or parabulbar injection. The first group consisted of emergency cases referred to the clinic. A second group of patients had received retrobulbar block at the hospital. All cases were collected and screened for the presence of antiplatelet therapy. RESULTS: Among roughly 160 000 patient records screened, 3 patients with grade IV retrobulbar hematoma were identified. Two of these patients were taking dual antiplatelet medications and 2 were on anticoagulation therapy during the time of retrobulbar or peribulbar anesthesia. None of the cases showed single medication platelet inhibition. The visual acuity of all patients stayed low at the 6-month follow-up (1.2 logMAR in 1 patient and no light perception in 2 patients). CONCLUSIONS: Retrobulbar hematoma is a rare but severe complication of retrobulbar anesthesia. With the high prevalence of dual platelet inhibition found in these cases, a prospective controlled trial seems unethical. In these high-risk patients, surgery should be performed under topical anesthesia if possible or general anesthesia if necessary. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Double consecutive retrobulbar hemorrhage in a high-risk patient in treatment with aspirin and warfarin.

Retrobulbar hemorrhage is a vision-threatening emergency that may occur spontaneously or following facial trauma, orbital surgery, endoscopic sinus surgery, and retrobulbar injections. It may determine visual loss because of central retinal artery occlusion, optic neuropathy from direct compression, or compression of the circulation from mechanical tamponade. In addition to a deterioration in visual acuity with total blindness in the most severe cases, several symptoms and signs can be found, such as a sudden onset of severe pain, proptosis, and ophthalmoplegia.The knowledge of past medical history and underlying medical conditions is crucial in patients with retrobulbar hemorrhages. In fact, patients with blood dyscrasias have to be considered high-risk patients due to their increased propensity for uncontrolled bleeding.The aim of this article was to present and discuss the management of a case of double consecutive retrobulbar hemorrhage in a high-risk patient in treatment with aspirin and warfarin.

[Vitamin K antagonist overdose induced blindness in an infant: an argument for a therapeutic educational program]. / Cécité secondaire à un surdosage en antivitamine K chez l'enfant : un argument pour l'éducation thérapeutique.

INTRODUCTION: Vitamin K antagonist (VKA) treatment is associated with significant risks and requires strict monitoring by measuring the international normalized ratio (INR), either by conventional methods or by self-measurement under medical supervision. We present a case of blindness occurring secondary to a moderate head injury, in a pediatric setting with no VKA therapeutic education. CASE REPORT: A 7-year-old child with a single ventricle had been operated on for a total cavopulmonary shunt at the age of 5 years. He took VKA therapy with an INR target between 2 and 3. After a head trauma, he had a frontal hematoma. His parents did not request a medical exam and did not check his INR. Six days after the injury, the INR was 2.23. The parents went to the emergency ward because the child had bilateral orbital hematoma. At admission, the INR was 5.6. The orbital hematoma was surgically evacuated in the emergency setting. Unilateral blindness occurred and remains a sequelae of the overdose. COMMENTS AND CONCLUSION: VKA treatment requires close supervision to prevent overdose, whose complications such as internal bleeding can have terrible consequences such as the case of blindness reported herein. This case report is a strong argument in favor of an educational program for children with VKA treatment.

Bilateral orbital haematomas in an anticoagulated patient with severe H1N1 influenza.

A previously healthy woman was admitted to the intensive care unit (ICU) with severe H1N1 influenza. She had prolonged hospital stay due to multiple complications of critical illness, including pelvic deep vein thrombosis (DVT), which was treated with subcutaneous enoxaparin. The patient was referred to the ophthalmology service for bilateral proptosis. On examination, she had bilateral tense proptosis, worse on the left side with exposure keratopathy. Laboratory tests showed that she had thrombocytopenia and raised activated partial thromboplastin time (APTT). A CT scan revealed well-circumscribed soft tissue density lesions in the superolateral orbits and was reported as bilateral lacrimal gland enlargement. However, based on a clinical suspicion of subperiosteal hematoma collection, a diagnostic tap was performed. Following aspiration of six mls of dark blood from the left superior orbit, there was a reduction of proptosis with improvement in chemosis and resolution of exposure keratopathy. Enoxaparin is one of several antithrombotic agents which are increasingly being used for DVT prophylaxis in severely compromised patients. Furthermore, ICU patients ventilated for prolonged periods are at risk of developing chemosis and exposure keratopathy. Thus, the clinician should maintain a high index of suspicion in identifying subperiosteal hematomas, when managing such cases. The spontaneous bilateral vision threatening subperiosteal hematoma was probably caused by a combination of enoxaparin therapy and prolonged ventilation.

Retrobulbar haemorrhage associated with chronic Gingko biloba ingestion.

Retrobulbar haemorrhage is a rare and potentially sight threatening complication after peribulbar local anaesthetic injection for cataract surgery. A case is reported of a woman who developed this complication and was subsequently found to have been taking Gingko biloba extract tablets which may have predisposed her to developing the haemorrhage.

[Orbital haemorrhage after medial canthus episclera (sub-Tenon's) anaesthesia]. / Hématome rétrobulbaire après anesthésie épisclérale au canthus médial.

Medial canthus episclera (sub-Tenon's) anaesthesia is a technique proposed as a suitable alternative to the more classical peribulbar block because of the greater reliability and more constancy in effectiveness. We report two cases of retrobulbar haematoma after sub-Tenon's anaesthesia, one with central retina artery compression needed anterior room punction. Sub-Tenon's anaesthesia, like peribulbar anaesthesia, can give also retrobulbar haemorrhage if the insertion of the needle is not limited to the anterior orbit.

Anticoagulation and cataract surgery: a review of the current literature.

The anticoagulated patient presenting for cataract surgery presents many dilemmas for anaesthetist and surgeon alike. Current evidence suggests that warfarin therapy significantly improves prognosis in patients with atrial fibrillation with coexisting cerebrovascular disease, and those with non-tissue prosthetic heart valves. Inadequate anticoagulation in these groups exposes them to higher risk of systemic embolic complications, which are frequently devastating. Warfarin is an extremely complex drug. Attempted cessation and recommencement of warfarin therapy may not only reverse anticoagulation for unpredictable periods of time but may also expose patients to a transient yet dangerous hypercoagulable state. In most instances this state represents an additive risk to the untreated disease for which warfarin is being prescribed. It is difficult to accurately measure risks of local anaesthetic blockade in anticoagulated patients as techniques are not standardized. Smaller needles and single injections appear safer with deep eye blocks, while sub-Tenon's block and topical techniques appear safer still, and acceptable provided patients and surgeons are happy with the conditions so created. Retrobullbar haemorrhage appears to occur more frequently in anticoagulated patients who have their anticoagulation continued up to the time of cataract surgery. Retrobulbar haemorrhage is also more frequent in this same group even when anticoagulation is ceased prior to surgery when compared to non-anticoagulated patients. Prognosis for visual acuity with retrobulbar haemorrhage is generally good, given an experienced surgeon is present to rapidly decompress the eye.