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 21-year-old male was assaulted in the face, visited a hospital in another area and was diagnosed with orbital and nasal bone fractures (Fig. ). After diagnosis, he visited the Oral and Maxillofacial Surgery of Kangwon-University Hospital the next day and was hospitalized for surgery. The patient had limited ocular movements and diplopia with upward and downward gaze, along with facial sensory impairment and nasal deformity. His visual acuity evaluated by preoperative ophthalmology was Rt. 0.3/Lt. 0.3. Two days after the injury, orbital wall reconstruction and nasal bone repair were performed under general anesthesia. On the 1st day, there was slight swelling, chemosis, and mild pain at the surgical site. The diplopia was almost improved, and there were no significant problems with his vision. The damaged skin sensation had also improved significantly. Therefore, corticosteroids were administered, and the patient’s course was monitored (dexamethasone 15 mg/day). On the second day of surgery, the patient complained of severe ocular pain and exhibited severe ocular protrusion. His vision also began to deteriorate rapidly, and ophthalmology asked for an evaluation. The CT showed retrobulbar hematoma (Fig. ). The patient’s right eye visual acuity decreased to 0.01, and the intraocular pressure was elevated. Lateral canthotomy and cantholysis were immediately performed to reduce the intraocular pressure, and the hematoma was removed under general anesthesia. The next day, the patient’s pain was significantly decreased, and chemosis was decreased, but diplopia was observed when the patient gazed downward. The visual acuity was 0.04. After that, the pain was almost improved. After 1 week, the patient’s visual acuity improved to 0.2, and the corrected visual acuity was 0.7. Three weeks after surgery, his visual acuity was improved to 0.3. At 7 weeks after surgery, both eyes were corrected to 1.2, and the diplopia was improved. At 6 months after surgery, his visual acuity was normal, and the scar was not noticeable; however, mild diplopia when gazing downward was still present (Fig. ).