Author: Andrew Tabner / Codes: IC5, IP1, IP2, OptP2, OptP3, RP4, SLO1, SLO3 / Published: 12/04/2019

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Management of acute retrobulbar haemorrhage

Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians

Authors

  • Amy Hughes
  • Susie Roy

What this paper adds

Illustrates that although ED clinicians of all grades can recognise the symptoms and signs of acute retrobulbar haemorrhage (RBH) and orbital compartment syndrome (OCS), the majority lack confidence and/or skill in performing the sight saving intervention of lateral canthotomy and cantholysis (LC/C).

This paper provides impetus for EM practitioners to revise and refine the skill of LC/C, and argues for its inclusion in the RCEM curriculum.

The Paper

Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians

Edmunds MR, Haridas AS, Morris DS, et al Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians Emerg Med J 2019;36:245-247.

Available here

Background

  • RBH with OCS is an uncommon but sight-threatening emergency
  • The treatment is with LC/C – the earlier the better – ideally <120minutes
  • For EM clinicians the most common cause is trauma (think squash/ golf ball/ kick to the eye), however other causes exist including eyelid surgery
  • RBH is usually caused by an arterial bleed (from infraorbital or anterior or posterior ethmoidal artery).The orbit is a closed space so the bleeding causes an increase in orbital pressure -> OCS.  This pressure reduces perfusion to the optic nerve and retina leading to ischaemia and ultimately permanent visual loss
  • EM physicians are skilled at a number of procedures. The RCEM curriculum includes things such as LPs and central line insertion as well rarer skills e.g. resuscitative thoracotomy.
  • LC/C is not currently part of the RCEM curriculum

Study Design

Online questionnaire sent on a single occasion to ED physicians in seven EDs around the UK from FY1 to consultant grade.

What was surveyed?

Participants were sent a case vignette of a patient presenting with classical symptoms and signs of RBH. A photograph was provided. A number of MCQs followed regarding diagnosis and management.  Perspectives on reasons for reluctance to perform LC/C were explored.

Outcomes

  • 190 responses received (70%). Of note, 46.3% were EM consultants
  • 8% correctly diagnosed RBH with OCS
  • 7% realised delay to LC/C could result in permanent visual loss
  • 7% responded that they would perform CT head/ orbits prior to performing LC/C
  • 7% would perform LC/C themselves
  • Reasons for not performing LC/C – lack of training (91.4%), not seen before (72.5%) and concerns about damaging the patients eye (49.5%)
  • 2% felt EM physicians needed more training in LC/C

Authors’ Conclusion

While cases of RBH with orbital compartment syndrome are infrequent, it is important that RBH management with the vital, sight-saving skill of LC/C is added to the RCEM curriculum. At present, though the majority of ED physicians can identify RBH, the minority are willing or able to undertake LC/C, potentially risking irreversible but avoidable visual loss.

Limitations (includes authors and our own)

  • Assessment was done using a case vignette. In real life cases of RBH may be complicated by patient intoxication or other trauma, so assessment is more difficult
  • In practice assessment/ management/ intervention occurs simultaneously and not in a stepwise fashion
  • Time to CT is less than ever
  • The organisational structure of those questioned was not considered
  • ENPs were not surveyed

Our take home

Taking a pragmatic standpoint, this paper certainly opens the conversation regarding the inclusion of LC/C as an RCEM curriculum defined skill. Certainly it provides incentive both for departments and us as clinicians to ensure that we have the necessary knowledge and skills to perform the sight saving procedure of LC/C.

RCEM curriculum coverage

  • CAP 29: red eye
  • HAP 32: visual loss
  • C3AP1d: major trauma – maxillofacial

#FOAMed Resources

RCEM Learning

  1. Eye – initial assessment
  2. Zygomatic and Nasal Injury

Also check out the RCEMLearning vodcasts on eye anatomy

eye anatomy part-1

eye anatomy part 2

eye anatomy part 3

Other

Chris Nickson also covered RBH with OCS in a LITFL Ophthalmology Befuddler