Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71, 155–161

Retrobulbar hematoma: A systematic

review of factors related to outcomes
Brian Christie a, Lisa Block a, Yue Ma a, Alexandra Wick a,
Ahmed Afifi a,b,*
a
Division of Plastic Surgery, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792
b
Department of Plastic Surgery, Cairo University, Cairo, Egypt

Received 30 July 2017; accepted 13 October 2017

KEYWORDS Summary Introduction: Retrobulbar hematoma (RBH), a rare but serious condition, can
Retrobulbar result in permanent vision loss. Although it is a known complication following trauma or facial
hematoma; fracture reduction, sinus surgery, or blepharoplasty, factors related to patient outcomes are not
Facial fracture; well-defined. A systematic review was performed to determine the relation of patient/
Outcomes;
treatment factors to outcomes.
Trauma;
Blepharoplasty;
Methods: Articles retrieved from a PubMed search (1989–2017) were reviewed. Demographic
Lateral canthotomy information, etiology, symptoms, and final vision outcomes were analyzed using Fisher’s exact
tests, single and multiple predictor logistic regression.
Results: Of 429 articles identified, 16 were included in the study. 93 cases of retrobulbar
hematoma were included. 74% occurred after trauma, while 26% occurred postoperatively. Onset
of symptoms occurred after approximately 24 hours. 28% received treatment within 1 hour, 54%
within 1–24 hours, and 18% after 24 hours. 51% had complete visual recovery, while 27% had partial
recovery, and 22% developed blindness. Older patients and patients who sustained trauma were
less likely to have a full recovery (p = 0.029, p = 0.023). Increasing number of symptoms trended
towards a prediction of blindness (p = 0.092). Surgical decompression and shorter time to treat-
ment were each highly predictive of full recovery (p = 0.024, p = 0.003) and decreased likelihood
of blindness (p = 0.037, p = 0.045); use of steroids was not found to be significant.
Discussion: Retrobulbar hematoma is a diagnostic and therapeutic emergency. Factors associ-
ated with improved outcomes include younger age, decreased number of total symptoms,
surgical decompression, and shorter time to treatment. If recognized and treated early with
surgical decompression, recovery of vision is possible.
© 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Sources of Funding: There are no sources of funding to report.

Disclosure: The authors have no commercial associations or financial conflicts of interest to declare in relation to the context of this
manuscript.
Presentations: This work has been presented at the 2016 Midwestern Association of Plastic Surgeons Annual Meeting in Chicago, IL.
* Corresponding author. University of Wisconsin-Madison, Division of Plastic Surgery, 600 Highland Avenue, Madison, WI 53792.
E-mail address: afifi@surgery.wisc.edu (A. Afifi).

https://doi.org/10.1016/j.bjps.2017.10.025
1748-6815/© 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
156
Introduction
Retrobulbar hematoma (RBH) is a rare but serious condition
that can result in permanent vision loss. It is a known surgi-
cal complication following facial fracture reduction (0.3%),
endoscopic sinus surgery (0.43%), blepharoplasty (0.055%),
and retrobulbar injection of anesthesia (0.44%).1–3 It is also
a common cause of post-traumatic blindness, especially
in the setting of orbital fracture.1,2,4,5 The incidence of
RBH in patients with orbital fractures is estimated to be
0.45–0.6%.2,5,6
The pathophysiology of retrobulbar hematoma relates to
bleeding and compression within the enclosed retrobulbar
space. As bleeding occurs within the fixed space, pressure
increases and the globe is displaced anteriorly. This process
leads to an increase in intraorbital pressure, stretching of
the optic nerve and optic vessels, and results in venous
compression, compromising outflow and increasing intraor-
bital pressure.1,2,4,6,7 Further increase in intraorbital pres-
sure leads to central retinal artery occlusion and decreased
perfusion pressures, ultimately causing an ischemic optic
neuropathy that manifests as loss of vision.1,2,4,6–9
Retrobulbar hematoma is a diagnostic and therapeutic
emergency and must be treated urgently to prevent perma-
nent blindness. Factors related to patient outcomes,
however, are unknown. The purpose of this study was to
perform a systematic review of published articles in order
to determine which patient and treatment factors are
related to outcomes. It was our hypothesis that improved
outcomes in cases of retrobulbar hematoma are directly
related to shorter time to treatment, and treatment with
surgical decompression as opposed to nonoperative
treatment.
Methods
Search methodology
A PubMed search (1989–2017) was performed using Medical
Subject Headings search terms for the following: (retrobul-
bar OR retroorbital) AND (hemorrhage OR haemorrhage OR
hematoma OR haemotoma OR bleeding). Results included all
ages and sexes, and were limited to the English language and
studies involving humans.
Exclusion criteria included case reports with fewer than 2
patients, studies with incomplete patient data, and studies
with no retrobulbar hematoma reported. Case reports on
subperiosteal hematoma were excluded as well.
Data extraction
The following variables were extracted into an Excel
(Microsoft Corp., Redmond, Wash.) sheet template devel-
oped before the query: lead author, publication year, age of
patients, etiology of retrobulbar hematoma, type of frac-
ture if traumatic etiology, presenting symptoms, time of
onset (hours), method of diagnosis (radiological or clinical),
time to treatment from symptom onset (hours), method of
treatment, and final vision outcome (full recovery, partial
recovery, or blindness). Blindness was classified using the
legal definition of blindness: visual acuity of 20/200 or worse.
B. Christie et al.
Statistical analysis
Two binary outcome contrasts were formed for the statisti-
cal analyses, in order to avoid multiple comparisons1: full
recovery versus partial recovery / blindness2; blindness versus
full / partial recovery. For each outcome contrast, Fisher’s
exact test was used to evaluate the association between
each categorical factor and the distribution of the two
outcome groups in the contrast. Single predictor and step-
wise multiple predictor logistic regression analyses were
applied to test the prediction from the factors to the likeli-
hood of an outcome compared to the other outcome group in
the contrast. All statistical analyses were performed using
SAS statistical software program version 9.4 (SAS Institute,
Cary, NC). A cutoff p-value of 0.05 was used for statistical
significance.
Results
Article selection
As shown in Figure 1, a total of 429 articles were identified
utilizing the initial query. Of these, 236 were excluded on
the basis of title, and 156 articles were excluded on the basis
of abstract content (Figure 1). Full review of article content
excluded an additional 21 articles based on absence of indi-
vidual patient data (n = 10), survey articles (n = 4), absence
of reported retrobulbar hematoma (n = 3), incomplete data
(n = 2), and fewer than 2 patients (n = 2). Sixteen studies
were thus identified and used for analysis (Table 1).
Patient demographics
There were a total of 93 cases of retrobulbar hematoma in
the 16 articles reviewed. Mean age of patients was 46 (range
10–92 years). There were 56 males (60%) and 37 females
(40%). Etiology was post-traumatic in 69 (74%)1–6,8–13 and
post-operative in 24 (26%).2,3,5,7,8,11,12,14–16 12 studies included
information about 49 facial fractures.1–4,6,8,11,13 Of the 69 post-
traumatic cases of RBH, 17 (25%) were due to motor vehicle
Figure 1 Search Methodology.
Retrobulbar hematoma: A systematic review of factors related to outcomes 157

acetazolamide was not included in analysis, as its use was

Table 1
only documented in two instances across all included cases.
Study No. of Patients The surgeries employed to decompress the orbit were vari-
Brucoli, et al. 2011 3 able, and included lateral canthotomy, transcutaneous/
Chen, et al. 2012 8 subcilliary transseptal decompression, pterional orbital
Cheon, et al. 2013 2 decompression, and external ethmoidectomy.
Colletti, et al. 2012 8 Visual outcome information was available for 89
Corey, et al. 1992 4 patients.1–16 45 patients (51%) had complete visual recovery
Gerbino, et al. 2005 8 without visual deficits,1–14,16 while 24 patients (27%)1,2,4–7,12,13,15
Goodall, et al. 1999 5 had partial recovery with some visual deficit, and 20
Hislop & Dutton, 1994 6 (22%)2,4,5,9,12,13 patients developed blindness.
Jamal, et al. 2009 2
Korinth, et al. 2002 15
Liu, 1993 2 Comparison of full recovery versus partial
Maurer, et al. 2013 6 recovery / blindness
Roccia, et al. 2011 8
Rosdeutscher & Stadelmann, 1998 2 Fisher’s exact test results demonstrated that patients with
Saussez, et al. 1998 2 an etiology of trauma (vs iatrogenic) were less likely to
Zimmerer, et al. 2014 10 have a full recovery (p = 0.031) (Table 2). When presenting
symptoms were analyzed, absence of blindness and absence
of pupillary disturbances were also associated with a full
recovery (p < 0.001, p = 0.047, respectively), while propto-
accidents,1,4,6,9,12,13 16 (23%) from fall injuries,3,4,6,9,10,12,13 15
sis was predictive of full recovery (p = 0.030). Regarding
(22%) from assault,1,8–11,13 and 21 (30%) from nonspecified
treatment, both surgery and time to treatment were asso-
injuries.2,5,6,13 Post-operative cases of RBH followed open
ciated with full recovery (p = 0.007, p < 0.001). Single pre-
reduction internal fixation (ORIF) of orbital fractures in 13
dictor logistic regression analyses showed that age was
cases (54%),2,3,7,8,11,12,15 endoscopic sinus surgery in 8 cases
found to be predictive of full recovery (p = 0.029), with older
(33%),2,14,16 blepharoplasty in 1 case (4%),5 and unspecified
individuals less likely than younger individuals to have full
orbital reconstruction in 2 cases (8%).5
recovery. An etiology of trauma (vs iatrogenic) was less likely
to have full recovery (p = 0.023). When presenting symp-
toms were analyzed, blindness, and pupillary disturbance
Timing of onset/onset characteristics were again predictive of partial recovery/blindness
(p < 0.001, p = 0.04), and both proptosis and reduced visual
Twelve studies included time of onset information for 44
acuity were again predictive of full recovery (p = 0.023,
patients.2–4,6–8,10–12,14,16 Average onset of symptoms appeared
p = 0.044). In terms of treatment, surgical intervention
20.5 hours after trauma (range 0–168 hours)2,4,6–8,10,12 and
(with or without steroids) and shorter time to treatment
29.8 hours after surgery (range 0–268 hours).2,3,7,8,11,12,14,16
were predictive of a full recovery (p = 0.024, p = 0.003).
Ten studies described method of diagnosis for 28
Stepwise multiple predictor logistic regression analysis
patients.1–12,14,16 57% of patients were diagnosed using
again indicates that shorter time to treatment was predic-
radiological criteria,1–7,9,10,12,15 while 43% were diagnosed
tive of a full recovery (p = 0.011).
using clinical exam.2–6,8,11,14,16 All 93 cases included informa-
tion concerning presenting symptoms, with 40 cases (44%)
presenting with reduced visual acuity1–12,14,15 (in 27 cases
(30%) the patient was legally blind at presentation), 37 Comparison of blindness versus full / partial
cases (40%) with proptosis,2,6,7,9–11,14–16 33 cases (35%) with recovery
pupillary abnormalities, 1–10,12,14,15 28 cases (30%) with
restricted extraocular movements,6,9,14,16 15 cases (16%) Fisher’s exact test results demonstrated that reduced visual
with increased intraocular pressures,1,3,8,16 and 14 cases (15%) acuity was associated with lower incidence of blindness
with pain.2–4,7,8,10,11,14 (p = 0.012), whereas, prior blindness was associated with
higher incidence of blindness (p < 0.0001). Regarding treat-
ment, both surgery and time to treatment were associated
Timing of treatment/treatment characteristics with lower incidence of blindness (p = 0.042, p < 0.001).
Single predictor logistic regression analyses showed
Time to treatment was available for 71 cases.1–4,6–8,12,14,16 20 that absence of reduced visual acuity, presence of prior
patients (28%) received treatment within 1 hour, while 38 blindness, and presence of reduced extraocular motion
(54%) received treatment between 1 and 24 hours, and 13 symptoms were predictive of higher probability of blindness
patients (18%) received treatment after more than 24 hours. (p = 0.016, p < 0.0001, and p = 0.047) (Table 3). Total number
Method of treatment was available for all 93 patients. 57 of symptoms (proptosis, reduced visual acuity, blindness,
patients (61%) received both surgery and steroids,1–8,11,13,15,16 pupillary disturbance, disturbance of EOM, increased ocular
while 26 patients (28%) underwent surgery only,1,6,7,9,11,14–16 4 pressure, and pain) trended towards a prediction of blind-
(4%) received steroids only,5,6 and 6 patients (6%) received ness (p = 0.092), with more symptoms being more likely to
neither steroids nor surgery. Administration of mannitol or result in blindness. In terms of treatment, both surgery and
158 B. Christie et al.

Table 2 Fisher’s exact test results summary.

Full Recovery vs Blindness vs Full/
Partial/Blindness Partial Recovery
Factor Total Sample Number with Percent with p-value Number with Percent with p-value
Size Full Recovery Full Recovery Blindness Blindness
Gender 1.000 0.796
Female 35 18 51.43% 7 20.00%
Male 54 27 50.00% 13 24.07%

Etiology 0.0307* 0.571

Iatrogenic 24 17 70.83% 4 16.67%

Traumatic 65 28 43.08% 16 24.62%

Proptosis 0.0299* 0.609
No 54 22 40.74% 11 20.37%
Yes 35 23 65.71% 9 25.71%

Reduced Visual Acuity 0.0556 0.0119*

No 49 20 40.82% 16 32.65%
Yes 40 25 62.50% 4 10.00%

Blindness <0.0001* <0.0001*

No 62 40 64.52% 6 9.68%
Yes 27 5 18.52% 14 51.85%

Pupillary Disturbance 0.0467* 0.118

No 58 34 58.62% 10 17.24%
Yes 31 11 35.48% 10 32.26%

Reduced Extraocular Motion 0.367 0.0567

No 61 33 54.10% 10 16.39%
Yes 28 12 42.86% 10 35.71%

Increased Intraocular Pressure 0.0513* 1.000

No 74 41 55.41% 17 22.97%
Yes 15 4 26.67% 3 20.00%

Pain 0.772 1.000

No 75 37 49.33% 17 22.67%
Yes 14 8 57.14% 3 21.43%

Number of Total Symptoms 0.878 0.421

0 14 7 50.00% 2 14.29%
1 21 13 61.90% 3 14.29%
2 17 9 52.94% 3 17.65%
3 21 10 47.62% 6 28.57%
4 11 4 36.36% 5 45.45%
5 2 1 50.00% 0 0.00%
6 3 1 33.33% 1 33.33%

Treated with Surgery 0.0074* 0.0417*

No 10 1 10.00% 5 50.00%
Yes 79 44 55.70% 15 18.99%

Treated with Steroids 0.375 0.108

No 30 13 43.33% 10 33.33%
Yes 59 32 54.24% 10 16.95%

Treatment Type 0.0429* 0.0427*

Surgery Only 24 12 50.00% 7 29.17%
Steroids Only 4 0 0.00% 2 50.00%
Both 55 32 58.18% 8 14.55%
Neither 6 1 16.67% 3 50.00%

Time to Treatment 0.0004* 0.0004*

Less than 1 hour 20 17 85.00% 0 0.00%
1 to 24 hours 37 19 51.35% 7 18.92%
Greater than 24 hours 12 2 16.67% 7 58.33%
Note: *p < 0.05.
Retrobulbar hematoma: A systematic review of factors related to outcomes 159

Table 3 Single predictor logistic regression analysis results summary.

Factor Full Recovery vs Partial/Blindness Blindness vs Full/Partial Recovery
N p-value O.R. 95% CI N p-value O.R. 95% CI
Age 89 0.029* 89 0.19
(every 1 Year increase) 0.98 (0.96, 1.00) 1.02 (0.99, 1.04)
(every 5 Year increase) 0.89 (0.81, 0.99) 1.08 (0.96, 1.21)
(every 10 Year increase) 0.80 (0.65, 0.98) 1.16 (0.93, 1.46)
Sex (Male vs. Female) 89 0.895 0.94 (0.40, 2.21) 89 0.653 1.27 (0.45, 3.58)
Etiology (Trauma vs. Surgery) 89 0.023* 0.31 (0.11, 0.85) 89 0.428 1.63 (0.49, 5.49)
Presence of Symptoms (Yes vs. No)
Proptosis 89 0.023* 2.79 (1.15, 6.75) 89 0.556 1.35 (0.50, 3.70)
Reduced Visual Acuity 89 0.044* 2.42 (1.03, 5.69) 89 0.016* 0.23 (0.07, 0.76)
Blindness 89 0.0002* 0.13 (0.04, 0.38) 89 <0.0001* 10.05 (3.24, 31.13)
Pupillary Disturbance 89 0.04* 0.39 (0.16, 0.96) 89 0.111 2.29 (0.83, 6.31)
Reduced Extraocular Motion 89 0.326 0.64 (0.26, 1.57) 89 0.047* 2.83 (1.01, 7.92)
Increased Intraocular Pressure 89 0.051 0.29 (0.09, 1.00) 89 0.802 0.84 (0.21, 3.32)
Pain 89 0.593 1.37 (0.43, 4.33) 89 0.919 0.93 (0.23, 3.72)
Number of Symptoms 89 0.264 0.85 (0.65, 1.13) 89 0.092 1.33 (0.96, 1.84)
Treatment (Yes vs. No)
Surgery 89 0.024* 11.31 (1.37, 93.62) 89 0.037* 0.23 (0.06, 0.91)
Steroids 89 0.332 1.55 (0.64, 3.76) 89 0.085 0.41 (0.15, 1.13)
Time to Treatment 69 0.003* 69 0.045*
Time between 1 and 24 hours vs 0.048* 5.28 (1.01, 27.46) 0.013* 0.17 (0.04, 0.68)
Time >24 hours
Time between 1 and 24 hours vs 0.018* 0.19 (0.05, 0.75) 0.954 >999.999 (<.001, >999.999)
Time <1 Hour
Time >24 Hours vs. Time < 1 Hour 0.001* 0.04 (0.01, 0.25) 0.948 >999.999 (<.001, >999.999)
Note: *p < 0.05.

Table 4 Stepwise multiple predictor logistic regression analysis results summary.

Factor Full Recovery vs Partial/ Blindness vs Full/
Blindness (N = 69) Partial Recovery (N = 89)
p-value O.R. 95% CI p-value O.R. 95% CI
Age NS NS NS NS NS NS
Sex (Male vs. Female) NS NS NS NS NS NS
Etiology (Traumatic vs. Iatrogenic) NS NS NS NS NS NS
Number of Symptoms NS NS NS NS NS NS
Treatment (Yes. Vs. No)
Surgery NS NS NS 0.037* 0.23 (0.06, 0.91)
Steroids NS NS NS NS NS NS
Time to Treatment 0.003* NA NA NA
Time between 1 and 24 hours vs Time >24 hours 0.048* 5.28 (1.01, 27.46) NA NA NA
Time between 1 and 24 hours vs Time <1 Hour 0.018* 0.19 (0.05, 0.75) NA NA NA
Time >24 Hours vs. Time < 1 Hour 0.001* 0.04 (0.01, 0.25) NA NA NA
NS = Not Significant
NA = Not Analyzed
* = p < 0.05
Note: *p < 0.05.

steroids, as well as shorter time to treatment were found to
predict lower likelihood of blindness (p = 0.037, p = 0.085,
and p = 0.045). Stepwise multiple logistic regression analyses
also indicated the possible effect of surgery in preventing
blindness (p = 0.037) (Table 4). Time to treatment was not
included in the stepwise multiple logistic regression analysis
for blindness vs. full/partial recovery because, given a zero
count of blind individuals who were treated in less than one
hour, the model could not be fitted with the predictor of
time to treatment included.
Discussion
Retrobulbar hematoma is a rare but serious condition that
can follow both trauma and elective surgery. While numerous
160
case reports and recommendations have been made, this
study represents the first systematic review that attempts to
leverage the multitude of patient reports against the paucity
of larger case series in an attempt to gather sufficient evi-
dence regarding factors related to patient outcomes. Through
analysis of the literature we have identified and analyzed 93
cases of retrobulbar hematoma represented in 16 included
studies. Overall, our review of visual outcomes suggested
that approximately half (51%) of patients had complete visual
recovery without visual defects, although 22% of patients
developed blindness. Our analysis of both precipitating factors
and treatment characteristics demonstrate that a number of
aspects have a significant impact on ultimate visual outcomes.
Our investigation of inciting factors demonstrates that
both trauma and surgery are well represented as causes for
retrobulbar hematoma. While multiple operative interven-
tions were identified as causal, the majority involved open
reduction and internal fixation of orbital fractures. Trauma
cases were significantly less likely to have a full recovery as
compared to surgical cases. This finding may be related to
the mechanism causing the hematoma itself, in which
postoperative bleeding caused by surgical instrumentation
tended to be less severe, or it could be related to monitoring
and thresholds to pursue imaging, which may be different
between trauma and operative patients. Additionally, factors
such as zone of injury or direct impact to the optic nerve in
addition to hematoma may play a role in the difference in
outcomes between an etiology of trauma or surgery. Age was
also found to be associated with recovery, as younger patients
were more likely to have improved visual outcomes.
Patients presented with a variety of signs and symptoms,
including reduced visual acuity, blindness, proptosis, pupil-
lary abnormalities, reduced extraocular movements, and
increased intraocular pressure.1–16 Pain, commonly described
as a herald sign for retrobulbar hematoma, was only described
in 15% of patients.2–4,7,8,10,11,14 The symptoms most strongly
predictive of full recovery were an absence of blindness and
absence of pupillary disturbances, while the presence of
blindness or reduced extraocular motion was strongly pre-
dictive of an outcome of blindness, suggesting that each of
these findings should alert the clinician to a more severe or
advanced process that should be dealt with immediately.
Additive number of total symptoms were associated with
blindness, suggesting that, as the pathologic process pro-
gresses, more symptoms present and make reversal of vision
loss less likely. Mean onset of symptoms for both trauma and
surgery occurred around approximately 24 hours. As peri-
ocular surgery is increasingly performed on an outpatient
basis, the need for close clinical follow up to ensure that
symptoms have not begun to develop should perhaps be
considered. Both clinical exam and radiological diagnosis
were common as diagnostic tools, suggesting that both are
viable and can continue to be utilized for initial identifica-
tion of retrobulbar hematoma.
Additionally, it was found that symptoms such as propto-
sis and reduced visual acuity were paradoxically predictive
of a full recovery and absence of reduced visual acuity was
also associated with blindness. While it is possible that these
symptoms could prompt earlier evaluation and treatment,
these findings were thought to be most likely due to lower
reporting of each individual symptom, as well as heteroge-
neous reporting of individual symptoms across all studies. It
B. Christie et al.
is unlikely, then, that these symptoms are truly predictive
of full recovery, and more likely an association between
symptom and outcome linking a particular study. This aber-
rancy is mitigated by analyzing total number of symptoms,
which suggested a trend towards increasing number of symp-
toms being predictive of blindness in single predictor logistic
regression analysis.
Time to treatment was variable among patients and dem-
onstrated a robust correlation with outcomes. While the
majority (82%) of patients received treatment within 24 hours,
only 28% of patients received treatment within 1 hour. Shorter
time to treatment was associated with more likelihood of
full recovery and less likelihood of blindness. This strongly
suggests that retrobulbar hematoma outcomes are extremely
time-sensitive, and confirms previous reports categorizing it
as an interventional emergency.
Our investigation of treatment modality also strongly con-
firmed that surgery is the preferred intervention, as it was
highly predictive of a full recovery and lower likelihood of
blindness compared to use of steroids alone or pursuance of
nonoperative management. While the addition of steroids to
surgery was not found to be statistically significant for improv-
ing visual outcomes, the overall intervention of steroids (with
or without surgery) trended towards an improvement in visual
outcomes, suggesting that, perhaps with a larger number of
cases represented, steroids in addition to surgery may prove
additionally advantageous.
Our study had some limitations, most of which are inher-
ent to any systematic review. Inclusion of a large number of
studies with a relatively small number of individual cases
can result in limitations of analysis of heterogeneous data, in
which certain data sets may become linked within a study. A
probable example of this phenomenon is in our findings of
proptosis and reduced visual acuity being paradoxically pre-
dictive of full recovery. Similarly, a number of various sur-
gical approaches were employed to operatively decompress
the orbit, and, when analyzed as individual operative inter-
ventions, lacked power to demonstrate any clear advantage
of one type of operative approach versus another.
In summary, our study is the first of its kind to systemat-
ically review factors associated with vision outcomes in
patients experiencing retrobulbar hematoma. These results
strongly suggest that vision and pupillary changes as well as
increasing total number of symptoms are indicative of a
more advanced or severe disease process associated with a
poor prognosis. As cases often present in a delayed fashion,
consideration should be made to closely follow up or observe
patients. Most importantly, they suggest that time to inter-
vention and surgical decompression are critical to improving
visual outcomes and preventing blindness, and the addition
of steroids may be of benefit. If recognized and treated early
with surgical decompression, recovery of vision is possible.
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