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 47-year-old male was involved in a traffic accident while driving in a car. Immediately after the accident, he visited our emergency room, and primary closure was performed. He was admitted to the Department of Oral & Maxillofacial Surgery for surgery of the orbital floor and medial wall fracture. His right eyelid had a wound of approximately 2 cm and was severely swollen so that his right eyeball was barely visible. Subconjunctival hemorrhage was present, and his vision was somewhat reduced. In the preoperative ophthalmologic examination, his visual acuity was 0.2 in the right eye and 1.0 in the left. There was a limitation of eye movement upward, and the patient experienced diplopia when looking forward and upward. Computed tomography revealed fracture of the right inferior and medial orbital wall and entrapment of the inferior rectus muscle with orbital fat herniation (Fig. ). Six days later, the surgery was performed, with reconstruction of the orbital wall. On the day of surgery, there was no specificity. However, at dawn on the day after surgery, the patient complained of severe pain and proptosis in the right eye and no vision. Retrobulbar hematoma was confirmed on CT, and the patient was consulted to ophthalmology. The intraocular pressure of the right eye did not appear to be high; thus, lateral cantholysis was not performed. The patient was followed-up with, and he was treated with systemic corticosteroids in a standard dosage for 3 days (dexamethasone disodium phosphate, 15 mg/day). However, his vision did not recover, and on the third postoperative day, the access was reopened, and hematoma removal was performed (Fig. ). One week later, his vision had not recovered, and ophthalmologic examination revealed blindness due to central retinal artery occlusion. The right fundus could be seen and showed a red spot, and white edema appeared to be caused by a complete CRAO. One month later, the optic disc appeared pale and atrophic (Fig. ).