Therapy of a chronic retrobulbar hematoma after endonasal sinus surgery
23 April 2019 (online)
The occurence of a retrobulbar hematoma is a typical, rare complication after endonasal sinus surgery. In the event of a critical increase of the intraocular pressure with acute endangerment of vision, in most cases an acute surgical decompression of the orbita is necessary. Here we report a case with initial conservative therapy, which enabled a fibrinous organization of the hematoma.
In a 71-year-old patient, a right-sided retrobulbar hematoma developed after endonasal sinus surgery. It was initially treated ex domo conservatively with antibiosis and cortisone therapy. After 3 months the patient presented with right-sided increased intraocular pressure (46 vs. 15 mmHg), visual loss (0.2) and diplopia in our clinic. After ophthalmic co-evaluation and imaging, we performed the urgent surgical orbital and optic decompression with subsequent i.v. antibiosis and i.v. cortisone therapy. Intraoperatively, a fibrotic-sheathed hematoma was found, which prolapsed into the right nasal cavity. After the procedure, a normalization of the intraocular pressure and an increase in vision (to 0,4 during the inpatient stay) was shown. The cortisone therapy was continued by mouth at discharge, followed by regular post-inpatient follow-ups.
The conservative treatment of the retrobulbar orbital hematoma should only be considered under close ophthalmological surveillance. If a compression of the optic nerve is suspected, rapid surgical relief should be provided. This may still be promising even if the hematoma has been present for some time. In postoperative retrobulbar masses, differential diagnosis should also include consideration of sclerosing lipogranuloma (paraffinoma), foreign body granulomas in response to intraoperatively installed fats. The diagnosis is made by histopathology.