TECHNICAL STRATEGY
Retrobulbar Hemorrhage During or After Endonasal or
Periorbital Surgery: What to Do, When and How to Do It
Giacomo Colletti, MD,
Paolo Fogagnolo, MD,y Fabiana Allevi, MD,
Dimitri Rabbiosi, MD,

Valentina Bebi, MD,z Luca Rossetti, MD,§ Matteo Chiapasco, MD,jj and Giovanni Felisati, MDz
Abstract: Retrobulbar hemorrhage (RBH) is an uncommon com-
plication of endoscopic sinus surgery or periorbital surgery con-
sisting in an accumulation of blood within the orbit posteriorly to
the eyeball. It must be treated within 90-100 minutes to avoid
irreversible visual loss. The present paper tries to pinpoint the key
steps in diagnosis and treatment of RBM.
On the wake of a new case, the authors review and update their
clinical experience and propose a step-by-step protocol to diagnose and
to treat RBH developing under different circumstances: during endo-
scopic sinus surgery, during periorbital surgery, immediately after the
surgery, in the awakening room, or postoperatively in the ward.
A therapeutic ladder is proposed that starts with lateral canthot-
omy and inferior cantholysis and progresses to a lower lid trans-
conjunctival incision with retrocaruncular extension.
Based on our experience, the proposed guidelines are effective
in diagnosing and treating RBH. They allow to preserve vision and
minimize reliquates of this rare and dangerous surgical emergency.
Key Words: inferior cantholysis, lateral canthotomy, retrobulbar
hemorrhage, transconjunctival access, transpalpebral management
(J Craniofac Surg 2015;26: 897–901)
R etrobulbar hemorrhage (RBH) is a rare entity. Accumulation of
blood posteriorly to the eye can occur as a consequence of
trauma to the orbit or the zygoma, after periorbital surgery, or after
endoscopic sinus surgery (ESS) (Figs. 1, 2). The event of RBH after
periorbital soft tissue surgery is extremely rare with a reported
0.0052% in blepharoplasties.1,2 Similarly, RBH as a consequence of
ESS is an unusual eventuality with a reported frequency of 0.002 to
0.006.3,4 One could imagine that this event could happen more
frequently during or after endoscopic oncological surgery in that the
lamina papyracea and the ethmoidal arteries are more likely
From the
Department of Head and Neck Surgery, Section of Maxillo
Facial Surgery, San Paolo Hospital, University of Milan, Milan; yG.B.
Bietti Foundation for Study and Research in Ophthalmology—IRCCS,
Rome; zDepartment of Head and Neck Surgery, Section of Otolaryngol-
ogy, San Paolo Hospital, University of Milan, Milan; §Department of
Head and Neck Surgery, Section of Ophthalmology, San Paolo Hospital,
University of Milan, Milan; and jjDepartment of Health Sciences,
Division of Oral Surgery, San Paolo Hospital, University of Milan,
Milan, Italy.
Received June 23, 2014.
Accepted for publication December 2, 2014.
Address correspondence and reprint requests to Giacomo Colletti, MD,
Piazza della Repubblica 1/a, 20121 Milan, Italy; E-mail: giacomo.
colletti@gmail.com
Level of Evidence: 4. Case series.
The authors report no conflicts of interest.
Copyright # 2015 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000001508
The Journal of Craniofacial Surgery  Volume 26, Number 3, May 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
damaged during these procedures. However, this is not the case
and RBH occurs with the same incidence during or after endoscopic
surgery for nasal inflammatory diseases. Therefore, expert surgeons
as well as less experienced ones would have to face RBH during
their careers.
If untreated, RBH can rapidly lead to loss of vision. Many authors
state that if RBH is treated appropriately within 90–100 minutes,
irreversible injuries are prevented. Conversely, any delay in diagnosis
or treatment of this true emergency can cause permanent visual loss.5
RBH onset determines 3 symptoms: pain, proptosis, and pro-
gressive decrease of visual acuity; pain and decrease of visual acuity
might be misdiagnosed if the patient is sleeping during or after
surgery. Only a minority of emergency senior house officers were
able to correctly diagnose RBH according to a recent paper.6 Even
when a correct diagnosis is made, treatment is often the result of the
doctor’s preferences and confidence with certain techniques. Based
on the results of a survey, few senior house officers were able to
choose and perform a correct surgical approach in case of RBH.6
The mechanisms behind visual loss in RBH are poorly under-
stood, but it is clear that reduction of intraorbital pressure is the key
to recovery. However, surgical maneuvers commonly advocated to
achieve this such as lateral canthotomy (LC) and inferior cantho-
lysis (IC) can, at times, be insufficient. Also, other therapeutic
options are available if hemorrhage is caused by arterial laceration
during endoscopic sinus surgery.
The aim of this paper is to provide protocol to manage RBH
during surgery in the OR, immediately after surgery when the
patient is in the postoperative monitoring area, and after surgery
when the patient is in the ward.
MATERIALS AND METHODS
Surgical Technique
Intraoperative Management During ESS
If an orbital hemorrhage is the result of the severing of the
anterior or posterior ethmoidal artery,7 then the surgeon will gently
remove the papyracea and try to cauterize the vessel. However,
if a RBH develops and quick resolution cannot be achieved with
this technique, an external approach must be immediately chosen
(see Results and Discussion).
Lateral Canthotomy
If the patient is awake, local anesthetic with 1:200,000 adrenalin
is injected in the lateral soft tissues of the orbit including the lateral
canthus, the underlying periosteum, and the upper malar region.
The conjunctiva is anesthetized with topical anesthetic drops
(oxibuprocaine 0.4%, Novesine or Benoxinate).
The upper and lower lids are retracted with small skin hooks and
the lateral canthus is incised (Figs. 3, 4). The skin incision is
protracted laterally and caudally for 7–8 mm. Some bleeding from
small vessels is to be expected and the latter have to be cauterized.
The dissection then deepens to the periosteum. Here, the wound is
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Colletti et al The Journal of Craniofacial Surgery
FIGURE 1. Clinical appearance of a retrobulbar hematoma after a blunt trauma
to the right eye. The eye is pushed ventrally and caudally with an evident
proptosis.
divaricated and the incision on the canthus is extended to involve
3 mm of its inner face which is covered by conjunctiva. Lateral
canthotomy achieves only minimal inferior lid release (Fig. 5).
Inferior Cantholysis
Again, the lids are retracted with the aid of 2 small hooks. The
lateral canthal insertion can be palpated as a hard inextensible
tendon bridging the lateral orbital rim and the lateral canthus. When
identified, this is sharply dissected (Fig. 6) and the lower lid
immediately becomes highly mobile8 (Fig. 7). Some remaining
fibrous connections between the tarsus and the periosteum can limit
lower lid mobility. These are promptly severed.
Inferior Transconjunctival Incision With
Retrocaruncular Extension
Holding the tarsus of the inferior lid with the forceps and
retracting it laterally and ventrally, the conjunctiva of the inferior
lid is unrolled. With small sharp-tip scissors, a blunt dissection is
made immediately deep to the conjunctiva caudally to the tarsus
(Fig. 8A). The dissection proceeds for 1 cm. Then the scissors are
removed and rotated 90 degrees inserting 1 blade under the con-
junctiva which is cut (Fig. 8B). This dissection goes on until the
caruncula lacrimalis is reached. At this point, the incision bends
cranially and runs 1–2 mm lateral to the caruncula until the con-
junctiva of the upper lid is reached. Again, the borders of the
incision in the lower lid are retracted with the aid of the hooks; the
inferior orbital rim is reached by blunt and sharp dissection, ventral
to the lower lid orbital septum. The periosteum of the rim is incised
(Fig. 9) and elevated. If needed, the periosteum of the inferior
orbital wall is elevated. At the level of the medial one-third of
the orbital rim, the origin of the small oblique muscle is found
(Fig. 10A) and elevated with the periosteal insertions.
FIGURE 2. Coronal TC of the same patient. A retrobulbar hemorrhage has
caused a hematoma in the cranial part of the right orbit.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 26, Number 3, May 2015
FIGURE 3. Lateral canthotomy. Presurgical drawing. The skin incision is
planned in a preexistent crease and is 8–10 mm long.
Retracting the wound margins, the dissection proceeds medially
towards the medial orbital wall. Care is taken to avoid the lacrimal
sac. This is accomplished by identifying the anterior and posterior
lacrimal crest. The dissection has to aim dorsally to the latter. This
dissection has to be made almost 90 degrees to the medial orbital
wall to avoid injury to the extraocular muscles. The periosteum of
the medial wall is incised and elevated (Figs. 10B, C).
Finding the Source of Bleeding
The orbital periosteum is elevated. If the cause of the bleeding
was ESS (and the papyracea was not widely removed), it is probable
to find a single breach in the wall and in the periosteum that allows
for prompt recognition of the source of bleeding. Frequently, the
anterior ethmoidal artery is responsible for RBH development in
these cases (Fig. 11). Bipolar coagulation allows a rapid resolution
of bleeding.
When RBH is the consequence of lid surgery, then the perios-
teum of the inferior wall must be incised and dissected. The
hematoma will show up and it must be evacuated. The bleeding
vessel must be carefully searched and coagulated; however, bleed-
ing may be sometimes absent.
If RBH is traumatic or develops after orbital surgery, then the
periosteum is likely already interrupted. The hematoma must be
entirely evacuated and the source of bleeding meticulously
searched. In our experience, the infraorbital artery is very frequently
the cause of RBH after traumas.
If hypotensive drugs have been administered during elective
surgery, then the anesthesiologist is asked to increase blood pressure
at levels normal for the patient. Operatory field is again carefully
inspected to find out any additional source of bleeding.
Then a Penrose drainage is placed from the site of the hematoma
to the lateral canthus.
The lateral canthus is reapproximated with one single stitch at
the end of the operation.
The definitive closure in layers will take place after 3–4 days.
FIGURE 4. Lateral canthotomy. Two skin hooks are used to retract the lids. The
canthus becomes clearly evident and is incised with a scalpel.
# 2015 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 26, Number 3, May 2015
FIGURE 5. Lateral canthotomy. Only minimal mobility is gained after the
canthotomy. The upper and lower arms of the canthus are only 4-5 mm
away from each other even if the incision has reached the periosteum.
RESULTS AND DISCUSSION
Apart from airway compromise, RBH is one of the few true
emergencies in head and neck surgery.9
Some pathophysiological mechanisms have been advocated
for RBH, but none has been demonstrated yet. Still, an increase
in intraorbital pressure with a compartment-like syndrome and/or
ischemia of optical nerve owing to direct pressure by the hematoma
or stretching of the optical nerve seems to be the most likely
mechanism.1,10,11
Even if the pathophysiology is still unclear, a number of studies
confirm that the key concepts for correct resolution of this com-
plication are a prompt diagnosis and quick surgical management.12
As demonstrated in an experimental setting by Hayreh and
Jonas,13 an increase in intraorbital pressure high enough to reduce
blood flow in retinal arteries can produce irreversible injuries if
protracted for more than 105 minutes. If the same noxa endures for
more than 240 minutes, then irreversible blindness with optic nerve
atrophy will result.
Some clinical studies suggest that there is a window time of
120 minutes before the onset of permanent injuries to the optic
nerve.14,15
In a previous paper, we have described our experience with 8
cases of traumatic and iatrogenic RBH.16 In that series, we were
able to surgically decompress the patients within 60-90 minutes in
all cases but one. All of the patients treated within 60-90 minutes
had a complete recovery of visual acuity. One patient was treated
with a delay of 12 hours and became blind.
We have observed and treated 1 additional case of traumatic
retrobulbar hemorrhage since then, and we have updated
FIGURE 6. Inferior cantholysis. The 2 blades of the scissors are placed over the
inferior arm of the lateral canthus. Its insertion on the periosteum is made clear
by retracting the lower lid with a forceps.
# 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Retrobulbar Hemorrhage
FIGURE 7. Inferior cantholysis. Cutting the periosteal insertion of the lateral
canthus allows a high degree of mobility to the lower lid. At least 15 mm of
distance between the upper and lower arm of the lateral canthus (arrows) have
to be obtained to decompress a retrobulbar hemorrhage.
consequently our surgical protocol. This patient, a 14-year-old
male presenting rapidly progressing proptosis, pain, and reduction
in visual acuity, underwent an immediate LC and IC 45 minutes
after a blunt trauma to the eyeball without fractures. Then the
definitive exploration of the orbit was carried out under general
anesthesia. No source of active bleeding was noted. The patient
recovered completely and showed no reliquates.
Discussion of traumatic retrobulbar hemorrhage is not within the
scope of the present paper. However, a 9-patient case series is one of
the largest in the literature, despite the majority of them being
already published. Therefore, our personal experience, in line with
the literature, suggests some considerations because the pathophy-
siology of RBH is shared by iatrogenic and traumatic cases.
The diagnosis of iatrogenic RBH would have to be made in
totally different settings. First, we differentiate between intraopera-
tive and postoperative occurrence of RBH.
Intraoperative Diagnosis of RBH
RBH can develop during ESS as well as during periorbital bony
and soft tissue surgery. These 2 conditions are different and have to
be discussed separately.
RBH Developing During ESS
A retrobulbar hemorrhage can develop during sinus surgery
even if it is considered to be an extremely rare event.
The diagnosis of RBH during ESS is essentially surgical. When
the surgeon severs one of the ethmoidal arteries, he or she must pay
FIGURE 8. Inferior transconjunctival incision. A, The lower lid is held with the
forceps and a subconjunctival tunnel is created with the scissor entering through
the canthotomy. B, The conjunctiva is cut 2 mm from the tarsal margin holding
1 blade of the scissors in the tunnel previously created.
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Colletti et al The Journal of Craniofacial Surgery
FIGURE 9. The periorbita is incised on the lower rim and the orbital fat herniates
immediately (arrow).
attention to accurately cauterize the orbital edge to avoid retraction
of the bleeding vessel. If the surgeon notes any laceration of an
ethmoidal artery and this latter retracts inside the orbit, then a high
index of alertness for the development of RBH has to be raised. As a
first maneuver, the surgeon can try to follow the route of the artery
inside the orbit by removing part of the lamina papyracea. This
allows to create a drainage route for the blood and one can try to
coagulate the vessel.
If, in the meantime, RBH is suspected because the eye
becomes proptotic and the pupillary reflex is lost, then an external
approach must be switched to immediately. By external approach,
we mean performing LC and IC and then, as described in the
technique section, accessing the medial orbital wall through a lower
lid transconjunctival access with retrocaruncular extension (see
Surgical Technique).
In this case, carrying on with the endonasal approach would
waste precious time.
Moreover, removing a major part of the lamina papyracea may
cause enophthalmos. The latter develops in untreated medial wall
fractures when the bony medial wall is fractured out and the orbital
periosteum is breached.17 The same mechanism is intentionally
provoked during endoscopic treatment of Graves-Basedow dis-
ease–related exophthalmos where, again, the medial orbital bony
wall is removed and the periosteum incised.18 Yet, we have no
direct experience about sequelae of endonasal management as we
always managed RBH by means of external approach.
On the other hand, an external approach is totally respectful on
orbital walls and therefore we consider it less prone to develop
enophthalmos. Moreover, an external palpebral approach will leave
inconspicuous sequelae, the most remarkable being a small scar at
FIGURE 10. A, The periosteum of the inferior orbital wall is elevated and the
insertion of the inferior oblique muscle (arrow) is cut. B, The dissection proceeds
towards the medial wall and the incision passes lateral to the caruncula lacrimalis
(small arrow) while holding the conjunctiva with the forceps (big arrow). C,
Finally, the medial wall is inspected.
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 26, Number 3, May 2015
FIGURE 11. Often the anterior ethmoidal artery is the source of bleeding. It is
clearly visible through a medial wall access. A, Cadaveric study of the anterior
ethmoidal artery (arrow). B, Surgical appearance of the anterior (small arrow)
and posterior (big arrow) ethmoidal arteries.
the level of the external canthus as our experience with 9 cases
suggests.
RBH Occurring During Awakening in the
Operatory Room After ESS
At the time of awakening, a rise in arterial pressure is likely to
occur. This can reopen an artery inadvertently severed during ESS.
The first thing to do is to remove the nasal packing and to elevate the
head of the patient. A free route of drainage for the orbital blood is
therefore obtained, even if this may cause massive bleeding from
the nose. Endoscopic reexploration may be time-consuming,
in particular if the instruments have been already removed from
the operatory table. We recommend to immediately perform an
external approach with LC and IC under local anesthesia. In the
meantime, the patient can be narcotized again and the definitive
treatment can be accomplished.
RBH Developing During or Immediately After
Periorbital Surgery
A retrobulbar hemorrhage can happen intraoperatively as a
result of orbital surgery (trauma, secondary corrections of enopthal-
mos, etc.) or on periorbital tissues (blepharoplasty, etc.).
RBH in these cases is likely caused by an arterial bleeding7 and
it will develop rapidly.
If surgery was performed under local anesthesia, then RBH is
suspected on the basis of rapidly developing proptosis and decrease
in visual acuity. Pain could be assent owing to the local anesthetic.
If RBH is suspected, an immediate canthotomy with inferior
cantholysis is accomplished (see Surgical Technique) in all cases
except if RBH develops during inferior subciliar or subtarsal access,
as it can be the case in lower lid blepharoplasty. In these circum-
stances, a lateral canthotomy and inferior cantholysis would pose
the lower lid at high risk of vascular compromise. Thus, in these
cases, the previous access is widened if necessary to gain access to
the orbital septum that is opened along with the orbital periosteum.
The inferior arm of the lateral canthus can be detached with this
access. Opening the septum and the periosteum and releasing the
canthus can significantly reduce the orbital pressure and allow for
the definitive management of the hemorrhage.
Any hematoma is then removed and the source of bleeding is
looked for and stopped. Whether this can be found or not, the wound
is left opened and a Penrose drainage is left in place. Forty-eight
# 2015 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 26, Number 3, May 2015
hours after, if no signs of recurrence of the RBH are noted, the
wound can be closed in layers.
RBH Occurring in the Monitoring Room After
Awakening
In this case, the RBH can be easily suspected by the following
triad: pain, proptosis, and decrease in visual acuity.
Pain can be difficult to evaluate and RBH must be suspected if
proptosis and visual impairment are noted. Even only rapidly
evolving visual impairment is an indication for immediate treatment
if accompanied by orbital ecchymosis or other signs of orbital
bleeding.
In this setting, nasal packing has to be removed and the head of
the patient has to be elevated. Then a bedside LC and IC have to be
made immediately under local anesthesia and the operatory room
prepared for definitive management through transconjunctival and
retrocaruncular approach.
Alternatively, if the patient was previously operated on through
any lid access, this is readily reopened under local anesthesia.19 The
operatory room is then prepared for definitive treatment of the
source of bleeding.
RBH Occurring in the Ward
The hemorrhage is suspected on the basis of the following triad:
pain, proptosis, and decreasing visual acuity.
Immediately, nasal packing is removed and the patient’s head is
elevated. Then LC and IC are performed under local anesthesia. In
the meantime, operatory room is alerted and definitive management
of the hemorrhage is accomplished under general anesthesia via a
transconjunctival approach with retrocaruncular extension to the
medial wall.8 Again, if the patient has a preexistent orbital access,
this is reopened under local anesthesia19 and any blood accumu-
lation evacuated while preparing the operating room for definitive
management.
Under all these circumstances, any effort has to be made to avoid
delay in treatment. If there is a clinical suspicion of retrobulbar
hemorrhage, then any instrumental confirmation would be point-
less. CT scans, ultrasound scans, and even tonometric measure-
ments, although useful,20 have to be asked only if they can be
performed immediately.12 One always has to remember that once
visual acuity decreases, there are at best 90–120 minutes left for
treatment.
Lateral canthotomy and inferior cantholysis are excellent first-
line maneuvers. They allow reducing the intraorbital pressure.
However, they cannot be considered sufficient. Definitive manage-
ment of intraorbital bleeding must be obtained to maximize the
chances of complete visual recovery. The surgeon must consider LC
and IC as a means to gain time for definitive treatment, which means
removing the retrobulbar hematoma that can directly compress or
stretch the optic nerve and stopping the source of bleeding.
The role of medical therapies, although probably useful,21 is
unclear. High-dose steroids, diuretics, and topical eye medications
have not proven to prevent the consequences of RBH. In our
opinion, they have to be considered as additional measures but
not as the proper treatment of RBH.
# 2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Retrobulbar Hemorrhage
CONCLUSIONS
As with other surgical emergencies, a straightforward decisional
process is of the uttermost importance. No delays in treatment have
to occur and bedside measures as well as definitive treatments have
to be performed as soon as possible once the diagnosis is made.
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