Table of Contents  
Year : 2018  |  Volume : 26  |  Issue : 2  |  Page : 133-136

An uncommon case of intraoperative retrobulbar hemorrhage following sub-tenon’s anesthesia: A case report

Department of Ophthalmology, University College Hospital, Ibadan, Ibadan, Oyo State, Nigeria

Date of Web Publication13-Feb-2019

Correspondence Address:
Dr. Patrick O Idam
Department of Ophthalmology, University College Hospital, Ibadan, PMB 5116 Ibadan, Oyo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njo.njo_18_18

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A 51-year-old woman presented to the eye clinic with complaint of poor vision OS. She had a visual acuity of 6/6−2 OD and Hand Motion OS. Pupillary examination revealed a round active pupil OD and a relative afferent pupillary defect OS, open angles on gonioscopy OU, cup/disc ratio of 0.5 OD and 1.0 OS and intraocular pressure of 19-mmHg OD and 39-mmHg OS. A diagnosis of bilateral primary open angle glaucoma was made. She was subsequently booked for bilateral trabeculectomy following failed medical therapy. Preoperatively, she had O’Brien facial block and sub-Tenon’s anesthesia prior to commencement of right trabeculectomy surgery. She coughed persistently and strained intensely throughout surgery. She was subsequently noted to have persistent shallowing of the anterior chamber toward the end of surgery with associated proptosis, chemosis, and subconjunctival hemorrhage. A diagnosis of intraoperative retrobulbar hemorrhage (RBH) was made, and she had prompt lateral canthotomy and 500-mg stat dose of tab acetazolamide. Following reduction of the proptosis, the eye was padded and she was placed on tab acetazolamide 250 mg 8 hourly, tab chymotrypsin/trypsin 500 mg 8 hourly, tab paracetamol 1 g 8 hourly, and tab prednisolone 60 mg daily. She was subsequently discharged on the 4th postoperative day following resolution of clinical features and improvement in bleb morphology. Sub-Tenon’s anesthesia rarely causes intraoperative RBH. Prompt recognition and urgent surgical intervention is key to successful management of this condition.

Keywords: Anesthesia, hemorrhage, retrobulbar, sub-Tenon’s

How to cite this article:
Olawoye OO, Idam PO, Ibukun FA. An uncommon case of intraoperative retrobulbar hemorrhage following sub-tenon’s anesthesia: A case report. Niger J Ophthalmol 2018;26:133-6

How to cite this URL:
Olawoye OO, Idam PO, Ibukun FA. An uncommon case of intraoperative retrobulbar hemorrhage following sub-tenon’s anesthesia: A case report. Niger J Ophthalmol [serial online] 2018 [cited 2023 Feb 4];26:133-6. Available from:

  Introduction Top

Retrobulbar hemorrhage (RBH) is a vision-threatening emergency ocular condition which results from rapid and progressive accumulation of blood in the retrobulbar space.[1] It could result from periocular anesthesia, orbital/lid surgery, trauma, or rarely spontaneously from an underlying ocular or systemic condition.[2] An advantage of sub-Tenon’s over retrobulbar injection is the lower risk of RBH associated with the former.[3] We present a case of RBH noticed intraoperatively during trabeculectomy surgery following sub-Tenon’s anesthesia and intraoperative Valsalva maneuver.

  Case Report Top

A 51-year-old woman presented with a 2-year history of gradual and progressive reduction of vision in the left eye. There was no antecedent trauma, redness, or pain. She was not a known hypertensive and had no prior history of bleeding disorders. Examination at presentation showed a visual acuity (VA) of 6/6−2 OD and hand movement (HM) OS, relative afferent pupillary defect OS, open angles on gonioscopy OU, cup to disc ratio (CDR) 0.5 OD and 1.0 OS, and intraocular pressure (IOP) of 19-mmHg OD and 39-mmHg OS. Central visual field 24-2 showed inferior paracentral/Seidel scotoma and nasal step OD. She was placed on various medications including Gutt timolol, Gutt dorzolamide/timolol, Gutt travoprost/timolol, and tab acetazolamide. She however had suboptimal IOP control due to poor drug compliance which she attributed to financial constraints. Consequently, she was counseled and scheduled for bilateral trabeculectomy with mitomycin C in view of disease progression and poor IOP control at clinic visits. Her immediate preoperative vital signs included blood pressure: 110/70 mmHg, pulse rate: 74 bpm, respiratory rate: 18 c/m, temperature: 36°C. VA was 6/6 OD and no light perception (NLP) OS, with total afferent pupillary defect (TAPD) OS, open angles on gonioscopy OU, CDR of 0.7 OD and 1.0 OS. Maximum medications administered while on admission reduced the IOP to 10-mmHg OD and 30-mmHg OS. The decision to operate was based on the presence of disease progression (increase in CDR from 0.5 to 0.7 over a 2-year period), as a result of poor drug compliance of the patient attributed to financial constraints.

Preoperatively, she had O’Brien facial block and then sub-Tenon’s injection just prior to commencement of right trabeculectomy. She coughed persistently and strained intensely throughout surgery. This could have been due to anxiety or a reaction to the anesthesia, as she had no cough prior to surgery. After the placement of the scleral flap, the anterior chamber was well formed. Anterior chamber remained well formed until almost at the end of conjunctival flap closure when she was noticed to have sudden and persistent shallowing of the anterior chamber with associated proptosis, marked periorbital swelling, and a tense orbit. Proptosis became more marked upon removal of the lid speculum. There was associated severe lagophthalmos and inability to appose the lids. She also had marked temporal chemosis and subconjunctival hemorrhage. A diagnosis of RBH was made, and she had a prompt lateral canthotomy received tab acetazolamide 500-mg stat and had ointment chloramphenicol applied on the exposed cornea. The proptosis gradually subsided within 1 h and the eye was padded. She was then placed on tab acetazolamide 250 mg 8 hourly, tab chymotrypsin/trypsin 500 mg 8 hourly, tab paracetamol 1 g 8 hourly, and tab prednisolone 60 mg daily postoperatively. On the 1st postoperative day, her VA in the right eye was 6/60 which improved to 6/18 with pin hole. She had marked periorbital edema, temporal chemosis, subconjunctival hemorrhage, a low-lying bleb with negative Seidel’s test, few folds in descement membrane, anterior chamber inflammatory cells of 2+, well-dilated pupil (iatrogenic), and clear lens with pigments on anterior lens capsule. Her IOP was 17-mmHg OD and 28-mmHg OS. Tab prednisolone was discontinued, and she was placed on tab acetazolamide 500-mg stat, tab Chymoral II tds, tab paracetamol, intravenous ciprofloxacin, subconjunctival gentamycin/dexamethazone, Gutt moxifloxacin, Gutt dexamethazone, Gutt atropine, and Gutt-fortified gentamycin OD [Figure 1][Figure 2][Figure 3][Figure 4].
Figure 1 Two hours post-op

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Figure 2 First day post-op

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Figure 3 Two weeks post-op

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Figure 4 Six months post-op

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She had sustained resolution of periorbital edema and improvement in bleb morphology and was subsequently discharged on the 4th postoperative day. She was followed up at the out-patient clinic and had complete resolution of periorbital edema and subconjunctival hemorrhage as well as a functional bleb with adequate IOP control. Her VA at 6 months postoperatively was 6/9 unaided and 6/9+2 with pinhole OD. The slight reduction in VA (from 6/6−2 at presentation) is most likely from the insipient cataract she had developed, possibly from chronic topical steroid use postoperatively. Her IOP at 6 months postoperatively was 16 mmHg without any IOP lowering medications, thereby relieving her of the financial burden which had hitherto resulted in noncompliance.

  Discussion Top

RBH is a rare ophthalmic emergency that requires prompt intervention to preserve vision.[2]

The epidemiology of RBH varies according to the etiology, spontaneous RBH being the most rare, with only 115 cases reported over a 24-year period in largest report.[4] Reported prevalence of RBH in various retrospective studies include posttraumatic: 0.45% to 0.6%,[5],[6] postretrobulbar anesthesia: 0.005% to 0.44%,[7],[8] with only two reported cases of RBH following sub-Tenon’s anesthesia,[9],[10] and postsurgical: 0.04% to 0.43%[11],[12] for various surgical procedures such as blepharoplasty and endoscopic sinus surgery. Although rare, association between RBH and blindness is strong, with an incidence around 48%.[13] However, blindness only occurs in 0.14% in patients that received proper and prompt treatment.[14]

The etiology of RBH is varied and includes spontaneous RBH, which usually occurs in the setting of an underlying predisposing factor such as orbital vascular anomalies or blood dyscrasias. Post-traumatic RBH could occur with or without orbital wall fractures. Postanesthesia causes are predominantly seen with local periocular injections, though there has been reports of RBH following general anesthesia.[15],[16] RBH more commonly occurs with retrobulbar and peribulbar injections; an advantage of sub-Tenon’s injection over the former is the lower risk of RBH associated with it.[3] Postsurgical causes include orbital wall repairs, eyelid surgeries, strabismus surgeries, endoscopic sinus surgeries, etc.[2]

There are no prospective studies on risk factors for RBH; however, common associations include hypertension, Valsalva maneuver, orbital vascular malformations, anticoagulant medications and blood dyscrasias,[2] etc. Our patient was not hypertensive. She was not on any anticoagulant medications and had no known blood dyscrasias. She however had Valsalva maneuver as she persistently coughed and strained during the course of the surgery, most likely from intense anxiety. The RBH in our patient could have been from a slow leak from the vortex veins in the vicinity of the sub-Tenon’s injection or leakage from an undiagnosed pre-existing orbital vascular anomaly, induced by the Valsalva maneuver.

Orbital contents are confined by bone in all directions except anteriorly, where it is restricted by the firm orbital septum. In addition, beyond 6 to 7 mm of acute proptosis, the optic nerve is stretched taut and limits further forward movement of the globe.[2] RBH results in orbital compartment syndrome, a potentially blinding condition.[17] Normal orbital pressure is approximately 4 mmHg and the mean arterial pressure of the ophthalmic artery approximately 80 mmHg. When the intraorbital pressure rises beyond the latter, the central retinal artery may occlude, leading to retinal ischemia.[2] There could also be central retinal vein occlusion, occlusion of the short and long posterior ciliary vessels with resultant optic nerve ischemia, or direct compressive optic neuropathy. All these could lead to irreversible visual loss if no intervention is instituted in as little as 90 min.[18] This underscores the importance for prompt recognition and timely intervention in cases of RBH.

RBH, if mild, may have no accompanying symptoms. However, severe RBH with resultant orbital compartment syndrome will present with symptoms of pain, visual obscuration/loss of vision, diplopia, and periocular swelling. Signs of RBH include decreased VA, expanding proptosis, periorbital edema, ophthalmoplegia, elevated IOP, subconjunctival hemorrhage, chemosis, afferent pupillary defect, absent central retinal artery pulsation, etc.[2]

The diagnosis of RBH is mainly clinical due to the emergent nature of the condition. However, in cases of uncertain etiology, investigations including blood work up, ocular ultrasound, and/or computed tomography (CT) scan/magnetic resonance imaging (MRI) may become necessary.[2]

Treatment of RBH is aimed toward lowering intraorbital and IOP to prevent orbital compartment syndrome and its dreaded complications. Any underlying or predisposing conditions have to be addressed as well. Due to the rare and emergent nature of the condition, there are no clinical trials to guide therapy. However, rapid surgical intervention remains the mainstay of treatment,[18] with adjunctive medical therapy including oral/intravenous acetazolamide, topical ocular hypotensives such as Gutt timolol/dorzolamide/brimonide, intravenous mannitol and corticosteroids, and pain relief medications. The surgical procedure of choice is a lateral canthotomy/cantholysis of the inferior and if necessary the superior canthal tendon as well. This may be augmented by an anterior orbitotomy through the lateral canthal wound if necessary.[2] If there is a lack of proficiency in performing lateral canthotomy/cantholysis, some authors have advocated a full-thickness incision through the central upper and lower lids.[19] Our patient had lateral canthotomy without cantholysis, which was adjudged to be adequate in this setting. However, the latter is often necessary for adequate orbital release in severe cases. When the above measures fail, an emergent inferior and/or medial orbital wall decompression may become necessary.[19] Prompt intraoperative recognition of RBH in our patient coupled with timely intervention may be responsible for the favorable outcome achieved in this case. Our patient responded well to lateral canthotomy, tab acetazolamide, tab chymotrypsin/trypsin, and tab prednisolone. There was no need for topical pressure-lowering medications, as the trabeculectomy surgery was successful, ensuring controlled IOP postoperatively.

  Conclusion Top

RBH is an uncommon, potentially vision-threatening complication of ocular anesthesia and surgery. Sub-Tenon’s anesthesia with Valsalva maneuver can be a cause of intraoperative RBH. Prompt recognition and urgent surgical intervention is key to successful management of this condition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hwang F, Hasan A. Retrobulbar hemorrhage. [Internet]. Available from: [Updated 2016 Mar 3; cited 2017 Oct 2].  Back to cited text no. 1
Lewis CD, Perry JD. Retrobulbar hemorrhage. Expert Rev Ophthalmol 2007;2:557-70.  Back to cited text no. 2
Kumar CM, Eid H, Dodds C. Sub-Tenon’s anaesthesia: Complications and their prevention. Eye (Lond) 2011;25:694-703.  Back to cited text no. 3
Sullivan TJ, Wright JE. Non-traumatic orbital haemorrhage. Clin Exp Ophthalmol 2000;28:26-31.  Back to cited text no. 4
Gerbino G, Ramieri GA, Nasi A. Diagnosis and treatment of retrobulbar haematomas following blunt orbital trauma: A description of eight cases. Int J Oral Maxillofac Surg 2005;34:127-31.  Back to cited text no. 5
Hislop WS, Dutton GN, Douglas PS. Treatment of retrobulbar haemorrhage in accident and emergency departments. Br J Oral Maxillofac Surg 1996;34:289-92.  Back to cited text no. 6
Edge KR, Nicoll JM. Retrobulbar hemorrhage after 12,500 retrobulbar blocks. Anesth Analg 1993;76:1019-22.  Back to cited text no. 7
Hamilton RC, Gimbel HV, Strunin L. Regional anaesthesia for 12,000 cataract extraction and intraocular lens implantation procedures. Can J Anaesth 1988;35:615-23.  Back to cited text no. 8
Olitsky SE, Juneja RO. Orbital hemorrhage after the administration of sub-Tenon’s infusion anesthesia. Ophthalmic Surg Lasers 1997;28:145-6.  Back to cited text no. 9
Rahman I, Ataullah S. Retrobulbar hemorrhage after sub-Tenon’s anesthesia. J Cataract Refract Surg 2004;30:2636-7.  Back to cited text no. 10
DeMere M, Wood T, Austin W. Eye complications with blepharoplasty or other eyelid surgery. A national survey. Plast Reconstr Surg 1974;53:634-7.  Back to cited text no. 11
Stankiewicz JA, Chow JM. Two faces of orbital hematoma in intranasal (endoscopic) sinus surgery. Otolaryngol Head Neck Surg 1999;120:841-7.  Back to cited text no. 12
Ansari MH. Blindness after facial fractures: A 19-year retrospective study. J Oral Maxillofac Surg 2005;63:229-37.  Back to cited text no. 13
Fattahi T, Brewer K, Retana A, Ogledzki M. Incidence of retrobulbar hemorrhage in the emergency department. J Oral Maxillofac Surg 2014;72:2500-2.  Back to cited text no. 14
Gunning KEJ, Collett BJ. Spontaneous retrobulbar hemorrhage following anesthesia. Anaesthesia 1987;42:875-6.  Back to cited text no. 15
Anderson KK, Larson NH, Saga-Rumley SA, Hamed LM. Spontaneous orbital hemorrhage during general anesthesia and arthroplasty. J Clin Anesth 1994;6:145-7.  Back to cited text no. 16
Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: The ophthalmic surgical emergency. Surv Ophthalmol 2009;54:441-9.  Back to cited text no. 17
Winterton JV, Patel K, Mizen KD. Review of management options for a retrobulbar hemorrhage. J Oral Maxillofac Surg 2007;65:296-9.  Back to cited text no. 18
McAllister AR, Sobel RK, Allen RC. Spontaneous retrobulbar hemorrhage with subsequent orbital compartment syndrome. Available from: [Updated 2013 Apr 18; cited 2017 Oct 2].  Back to cited text no. 19


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