A 34-year-old man without any underlying disease was transferred to our hospital for swelling of the left periorbital area after being hit by a baseball. An orbital computed tomography (CT) scan showed an orbital floor fracture (). Reconstruction of the depressed orbital floor with porous polyethylene implant (Medpor; Porex Corp., College Park, GA, USA) and insertion of a negative pressure drainage tube were performed. Before surgery, ophthalmologists confirmed the absence of abnormalities on the left eye. No complications were observed until the third postoperative day. On the 4th postoperative day, the patient went outside and smoked a cigarette. It was winter at the time, and the temperature was –3°C. A few hours later, the patient suddenly presented with severe eye pain, edema, and chemosis. Relevant medical information including vital signs and smoking history are presented in . The patient’s blood pressure and pulse rate were slightly increased after the onset of these symptoms. Unilateral proptosis and a dilated pupil were observed and the patient’s visual acuity on his left eye decreased from 20/20 initially to hand motion. A diagnostic enhanced facial CT scan revealed a 22× 16× 12 mm retrobulbar hematoma and 25 mm of exophthalmos (-). Since the signs of retrobulbar hematoma were unequivocal, a decompression procedure was immediately performed without measuring the intraocular pressure. Bedside decompression via suture removal was performed immediately. Medical treatment including intravenous steroids and 20% mannitol were administered simultaneously. Approximately 2 hours after the onset of initial symptoms, emergency exploration under general anesthesia was conducted (). Intraoperatively, 3 mL of hematoma as a form of fluid collection was evacuated from the inferior portion of the orbital cavity near the previously inserted Medpor. The quantity of hematoma was also measured as 3.025 mL using the picture archiving and communication system software, Dejaview (Dongeun IT, Bucheon, Korea). Active arterial bleeding was not seen, but diffuse oozing was observed. Meticulous hemostasis was performed after removal of the Medpor. A negative pressure drainage tube was inserted, and the wound was closed. No abnormal findings were observed during the postoperative ophthalmic examination. Subsequently, visual acuity on his left eye was restored to 20/20. On the 4th postoperative day, the drainage tube was removed. On the seventh day, the patient was discharged. No complications were observed in subsequent follow-up examinations at 1, 2, and 4 weeks, and protrusion of the left eye also resolved ( and ).
A healthy 20-year-old man complained of discomfort in his left eye caused by assault. His visual acuity and intra-ocular pressure were normal. The physical examination showed no signs of diplopia or gaze limitation. However, since there were computed tomography (CT) findings of an approximately 21 mm×18 mm fracture, and trapping of the ocular content and the inferior rectus muscle accompanied by displacement of the left orbital floor (), orbital wall reconstruction was performed using a re-absorptive polymer mesh (Floor liner, Medtronic, Minneapolis, USA) seven days after the injury. It was performed without difficulty and there was little bleeding in the operation field. The light reflex in both eyes was normal after the surgery, and there were no specific ocular symptoms other than subconjunctival hemorrhage (). On the fifth day, the patient's visual acuity and intra-ocular pressure were restored to preoperative levels, so the patient was discharged without any specific symptoms. Ten days after the reconstruction, the patient visited our hospital complaining of loss of sight two to three days earlier. The patient considered the symptom temporary following surgery, and there were no accompanying symptoms such as pain. As for the visual acuity, the patient did not perceive light and was positive for relative afferent papillary defect. His intra-ocular pressure was normal, and there were no specific findings during the ophthalmic examination. A CT scan was immediately performed. Since retrobulbar hematoma up to the apex was observed (), the authors immediately removed and decompressed the hematoma and started systemic steroid therapy (250 mg per 6 hours of methylprednisolone for three days, and steroid tapering). However, there was no visual recovery.