Fig. 11.3 Eyelid, subconjunctival and orbital hemorrhage

Medical Management

Intraoperatively, achievement of hemostasis is crucial in prevention of retrobulbar hemorrhage. In the postoperative period, one may consider the use of antiemetics and antitussives to help prevent Valsalva, a possible trigger for bleeding [9]. Conservative management may include the use of systemic corticosteroids to reduce soft tissue edema. If intraocular pressure is elevated, the use of topical or systemic medications to control intraocular pressure may be used to temporarily protect the optic nerve. However, treatment of elevated intraocular pressure may not be useful as the elevated intraocular pressure is due to transmitted intraorbital pressure from the space-occupying hematoma. Decreasing the intraocular pressure in the face of increased orbital pressure may further diminish intraocular blood flow. In cases where vision is intact and the hematoma is felt to be stable, progression can be followed with monitoring of the pupils, color plates, exophthalmometry, intraocular pressure, and serial Humphrey or Goldmann visual field testing.

Surgical Management

Ultimately, to prevent permanent vision loss from a retrobulbar hematoma with orbital compartment syndrome, urgent surgical intervention is required. The blepharoplasty incision is opened and the tissues are explored, cauterizing or ligating any potential sources of bleeding. Any visualized clots are excised and compartmentalized blood evacuated. If the patient’s presenting condition is severe or worsens, then a lateral canthotomy and cantholysis with or without orbital decompression may be performed to decrease intraorbital pressure [14, 15]. Often, the canthotomy and cantholysis are

adequate to control the intraorbital pressure and protect vision. If not, decompression of the orbit proceeds with fracture of the orbital floor and rarely the medial wall depending on the amount of volume expansion required for adequate pressure reduction. The canthus can be repaired days later to allow for further drainage if there is concern of additional hemorrhage. Conversely, the canthus may be allowed to heal spontaneously with future revision if necessary.

Following surgical intervention, adequate reduction of intraorbital pressure must be assessed. As discussed in the previous section, the patient is closely followed with monitoring of visual acuity, pupillary reactions, color plates, exophthalmometry, intraocular pressure, and serial Humphrey or Goldmann visual field testing. The obvious goal is restoration of vision and all measured parameters to the preoperative state. The key to success in all cases is the early recognition of the signs and symptoms of retrobulbar hemorrhage and aggressive immediate intervention, which provides the best chance of regaining vision [16].

11.2.2 Vision Loss

11.2.2.1 Orbital Compartment Syndrome

Orbital compartment syndrome describes a condition where there is an increase in intraorbital pressure within the confined orbital volume [17]. When the intraorbital pressure exceeds the arterial pressure, optic nerve or choroidal ischemia may lead to irreversible vision loss. In upper blepharoplasty, orbital compartment syndrome can occur secondary to a space-occupying retrobulbar/intraorbital hemorrhage. Retrobulbar/intraorbital hemorrhage and treatment options are discussed in the previous section.

11.2.2.2 Globe Rupture/Perforation

Globe rupture or perforation can occur during any periocular surgery. When performing upper blepharoplasty, the globe is at risk for perforation during injection of local anesthetics, incision, dissection, and suturing. Globe rupture is an ophthalmic emergency and can lead to permanent vision loss. Perforation risks can be decreased by the use of plastic or metallic corneoscleral protective shields (OculoPlasik, Montreal, Canada), placed prior to surgery. A topical ocular anesthetic, such as tetracaine ophthalmic, should be placed in each eye prior to insertion of the shields. If the case is prolonged, anesthetic should be applied approximately every 45 min or when the patient complains of ocular discomfort. If using laser for incision or dissection, a nonreflective metallic scleral shield is useful for corneal and globe protection.

Medical Management

The placement of a corneoscleral shield at the start of surgery and proper injection and surgical technique can help decrease the chances of globe perforation, but the shield