Fig. 11.1 Diffuse superficial hemorrhage following bilateral upper blepharoplasty in a patient who did not discontinue his daily 81 mg aspirin

Fig. 11.2 Computed tomography of the orbits (axial) shows proptosis and a compartmentalized intraorbital hemorrhage posteromedial to the left globe

and evaluating for proptosis, as a collection of blood in the orbit is more likely to threaten vision than a similar collection in the eyelid. If there is clinical uncertainty, a computed tomography (CT) scan of the orbits may be performed to confirm or help exclude the diagnosis of orbital hemorrhage (Fig. 11.2). In the absence of a retrobulbar hematoma, treatment should begin with conservative medical management.

Medical Management

The first step in the management of intraoperative hemorrhage is to identify and control any source of active bleeding. Small leaks may be initially controlled with direct pressure held over a period of time. For bleeding at the skin edge, this is sometimes preferable as cautery may cause thermal damage to the epithelium. If the surgical wound is closed and active bleeding is noted, this may necessitate reopening the wound, identifying the source of bleeding, and reapplying cautery. For actively “pumping” arteries, a forceps or hemostat is used

to grasp the vessel and stop the flow of blood. Cautery is then applied to the metallic instrument and transmitted to the tissue. In the rare circumstance that cautery is unsuccessful, thrombin, or gelfoam soaked in thrombin may be applied to the area to aid in hemostasis. If bleeding persists the vessel can be ligated with a suture when possible.

When a patient returns for a postoperative visit with an eyelid hematoma, and in the absence of active bleeding, treatment involves cold or warm compresses depending on the timing. For a diffuse (interstitial) collection of blood in the first 24–36 h after surgery, a cold compress will vasoconstrict blood vessels and decrease swelling, bleeding, and bruising. After this time, heat may speed up the breakdown and resorption of the blood. Small sequestered hematomas can be followed clinically (with compresses as above) until liquefaction has occurred. If the hematoma is localized and larger, needle aspiration should proceed. Patients who report bleeding after surgery should suspend anticoagulant therapy if medically possible. There are also many supplements and foods that affect the natural clotting process and should be discontinued until resolution of the hematoma [6] (Table 11.1).

Surgical Management

In severe or refractory cases, surgical exploration is necessary to identify and control the source of bleeding. Hematomas that continue to expand can be worrisome and lead to orbital compartment syndrome with possible permanent loss of vision.

11.2.1.2 Retrobulbar/Intraorbital Hemorrhage

Retrobulbar or intraorbital hemorrhage (Figs. 11.2 and 11.3) is one of the most feared complications of blepharoplasty. Retrobulbar hemorrhage causing orbital compartment syndrome is the most common cause of postoperative permanent vision loss. Presentation is commonly within the first 3 h after surgery, with the risk diminishing substantially after 24 h. Although less likely, hemorrhage can occur on a delayed basis. [7, 8]. In a questionnaire of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS), Hass et al. noted the incidence of retrobulbar hemorrhage after blepharoplasty to be 0.05% and retrobulbar hemorrhage associated with permanent vision loss 0.0045% [9]. The mechanism of permanent vision loss from retrobulbar hemorrhage is believed to be elevated intraocular and intraorbital pressure caused by the space-occupying hematoma. The rise in pressure can lead to compressive optic neuropathy or vascular ischemia of the optic nerve or retina [10–12].

Risk factors for retrobulbar hemorrhage are: thyroid associated orbitopathy, blood dyscrasias, hypertension, atherosclerosis, vascular disease, and anticoagulation [13]. Careful assessment of the patient’s risk factors for hemorrhaging

should be performed prior to performing blepharoplasty. Any patient who complains of a constellation of symptoms including pain, asymmetric swelling, proptosis, dimming of vision, or loss of vision following blepharoplasty may have a retrobulbar hemorrhage and must be evaluated and treated promptly. A complete ophthalmic examination, including

visual acuity, pupil assessment, intraocular pressure, and dilated fundus examination is performed. However, if the clinical suspicion is high, none of these assessments should delay emergent surgical exploration. Clinical examination is usually sufficient for diagnosis, but as mentioned previously, orbital CT may be a useful adjunct.