- Email: [email protected]
Impact of antithrombotic treatment in orbital haematoma
G Model
JORMAS-189; No. of Pages 4 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
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Original article
Impact of antithrombotic treatment in orbital haematoma N. Graillon a,*, J.M. Foletti a, M.K. Le Roux a, M. Alessandrini b, M. Benzaquen a, L. Guyot a a b
Oral and Maxillofacial surgery department, North hospital, assistance publique hoˆpitaux de Marseille, chemin des Bourrely, 13915 Marseille cedex 20, France Aix Marseille Universite´, SPMC EA 3279, 27, boulevard Jean-Moulin, 13385 Marseille, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 January 2018 Accepted 11 May 2018
Introduction: Orbital haematomas threaten the visual prognosis, but no treatment guidelines have been proposed. Antithrombotics could affect their prognosis and treatment. This study aimed to evaluate the effect of antithrombotics in the management of orbital haematomas and to suggest a standardised protocol. Material and methods: We conducted a retrospective study by sending a standardised questionnaire to 20 French maxillofacial surgery university departments to collect all the cases of orbital haematoma. Results: Twenty-five cases from 10 centres were collected, including five patients treated with anticoagulant and one patient treated with dual antiplatelet. Antithrombotics increased the risk of amaurosis and ocular disorders significantly. Surgery was performed for 66.7% of patients treated with antithrombotic and for 89.5% of other patients. Surgical delay was longer in patients treated with antithrombotic. Surgical drainage was used in most of the cases, whereas canthotomy with inferior cantholysis was the least-used technique. Conclusion: Antithrombotics appear to worsen the functional prognosis of orbital haematomas. A surgical management of orbital haematoma in patients treated with antithrombotics is not contraindicated. Surgical delay must be shortened as much as possible. A lateral canthotomy with inferior cantholysis seems to be an appropriate solution.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Orbital haematoma Orbital surgery Antithrombotic Anticoagulant
1. Introduction Orbital haematoma is a rare condition that can threaten the visual prognosis. Two localisations have been emphasised: subperiosteal and intraorbital, the latest being located either in intra- or extraconal space [1]. Orbital haematoma mainly occurs after middle-face trauma, surgical reduction of orbital and zygomatic fractures, orbital and eyelid surgery [2–4], endoscopic sinus surgery [2] or retrobulbar injections [5]. They can also develop spontaneously or after a minor trauma, all the more so if combined with antithrombotic drugs. Older people are more exposed to orbital haematoma [2] from their specific comorbidities (stroke with antithrombotic prescription, collapse). Due to the ageing of the population, more and more bleeding complications will be noticed after facial trauma, and appropriate protocols should be established for optimal care. Because orbital haematomas are very rare, no treatment guidelines have been proposed yet [2]. Surgical treatment is not always the best available option. Orbital
* Corresponding author. Service de chirurgie maxillo-faciale et stomatologie hoˆpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France. E-mail address: [email protected] (N. Graillon).
haematoma evacuation may lead to a significant worsening of visual function, especially for intraconal localisation and when antithrombotic drugs are involved. This study aimed to evaluate the effect of antithrombotic drugs (anticoagulant and antiplatelet) in the management of orbital haematomas in France and to suggest a standardised protocol. 2. Material and method We conducted a retrospective study from June 2013 to June 2016 by sending a standardised questionnaire to 20 French maxillofacial surgery university departments (Appendix A). We collected all the cases of orbital haematoma and analysed the data regarding management and treatment. For each case, background, symptomatology, diagnosis, treatment and evolution of the patient were noted on the questionnaire. Some items specifically focused on antithrombotics and their management. Patients were divided in two groups: group 1 for patients treated with antithrombotic drugs (ATT) and group 2 for patients without antithrombotic drugs (NoATT). Haematomas were classified into three localisations: retrobulbar (intraconal) when the haematoma was located in the cone constituted by the extraocular muscles, extraconal when the
https://doi.org/10.1016/j.jormas.2018.05.004 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004
G Model
JORMAS-189; No. of Pages 4 N. Graillon et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
2
haematoma was located in the periorbita outside the cone constituted by the extraocular muscles and subperiosteal when the haematoma was located outside the periorbita. 2.1. Ethical considerations This study was conducted in accordance with the principles of the Helsinki Declaration (2013). 2.2. Statistical analysis For descriptive analyses of the sample characteristics, data were expressed as proportions for the qualitative variables and as the means, standard deviations, median and interquartile range (IQR) for continuous variables. Comparisons between groups with and without anticoagulant treatment within the sample were evaluated using nonparametric Mann–Whitney tests for the continuous variable and using Chi-square or Fisher’s exact tests for qualitative variables with odds ratios (OR) and their 95% confidence intervals (95% CI), estimated using the bootstrap method (n = 1000 samples) to assess the degree of associations. All the tests were two-sided, and statistical significance was defined as P0.05. The statistical analyses were performed using the SPSS version 17.0.2 software package (SPSS Inc., Chicago, IL, USA).
3. Results Twenty-five cases from 10 centres, 15 men (60%) and 10 women (40%), were collected. Results are summarised in Table 1. Patients were divided in group 1 (antithrombotic treatment, n = 6) and group 2 (no antithrombotic treatment, n = 19). Five patients were treated with anticoagulant therapy such as antivitamin K, with one overdosed (international normalised ratio [INR] = 7). One patient was treated with dual antiplatelet (acetylsalicylic acid + clopidogrel). The average age of patients was 50 years. Patients treated with antithrombotics (group 1) were significantly older than other patients (group 2) (P = 0.0017). Table 1 Comparison of characteristics of the patients treated with antithrombotics (group 1) and without antithrombotics (group 2).
Age (years) Effect ifs (n) Aetiologies Traumatic Postoperative Others Localisations Retrobulbar Extraconal Subperiosteal Medical treatment Surgical treatment including Lateral canthotomy with inferior cantholysis Orbital bone decompression Evacuation Approach reopening Surgical delay 6h >6h Sequelae Amaurosis Visual acuity decrease Oculomotor disorders None
Antithrombotics (group 1)
Non-antithrombotics (group 2)
80.4 6 (5 AVK, 1 DAP)
41.9 19
83.3% 0 16.7%
63.2% 31.6% 5.3%
66.7% 33.3% 0 66.7% 66.7% 15%
31.6% 31.6% 36.8% 36.8% 89.5% 17.6%
50% 75% 0
29.4% 70.6% 35.3%
33% 33%
57.8% 26.3%
66.7% 0 33.3% 16.7%
5.3% 10.5% 5.3% 73.7%
Facial trauma was the most frequent cause (68%) of orbital haematoma, with seven orbital floor fractures, two zygoma fractures, one orbital roof fracture, one sphenoidal fracture and one case of facial trauma without any fracture. We noted one case of spontaneous haematoma in group 1 (ATT) without antithrombotic overdose. Six patients in group 2 (NoATT) presented a postoperative haematoma, complicating four reductions of orbital floor fracture, one reduction of zygoma fracture and one bone orbital decompression in Grave’s disease. One case was due to a barotrauma in scuba diving. Three patients in group 1 (NoATT) presented hypertension versus 2 patients in group 2 (NoATT). No other coagulation disease was found. A facial bone CT scan was performed for 21 patients. Four patients presented a suggestive symptomatology after orbital surgery and were directly transferred to the operating room without any imaging. Localisation was most frequently retrobulbar (four patients) in group 1 (ATT). Two patients presented an extraconal localisation in group 1 (ATT). The repartition was different in group 2 (NoATT), with seven subperiosteal haematomas, six retrobulbar haematomas and six extraconal haematomas. Medical treatment was prescribed for four patients (66.7%) in group 1 (ATT) and for seven patients (36.8%) in group 2 (NoATT). Surgery was performed on four patients (66.7%) in group 1 (ATT) and 17 patients (89.5%) in group 2 (NoATT). Surgical drainage was used in most of the cases, whereas canthotomy with inferior cantholysis was the least-used technique. Surgical delay was longer in patients of group 1 (ATT). Two patients in this group were operated on the day of the occurrence of the haematoma, four hours and six hours after the symptoms occurred. Another patient of group 1 (ATT) was operated two days later, and the last one was operated five days later. In group 2 (NoATT), 15 patients were operated within eight hours after the onset of symptoms. Two patients were operated after this delay. The first one was operated five days after the appearance of the symptoms because he did not consult before, and the second one was operated 22 days after the appearance of the symptoms, due to a poor initial neurological prognosis. Antivitamin K was prescribed for one nonsurgical patient, relayed by low-molecular-weight heparin for one patient and stopped for three patients, including the overdosed patient. This patient received vitamin K. The patient treated with dual antiplatelet was switched to aspirin. Five patients (83; 3%) in group 1 (ATT) presented permanent aftereffects due to orbital haematoma, versus three patients (26.3%) in group 2 (NoATT). Amaurosis was the most frequent complication in group 1, present in 66.7% of the cases (4 patients) versus 5.3% (1 patient) in group 2. Antithrombotics increased the risk of amaurosis (P = 0.005) significantly, with an odds ratio of 34 [3; 96], and the risk of ocular disorders (P = 0.035) with an odds ratio of 17 [1.6; 85]. In total, antithrombotics significantly reduced the recovery of visual acuity (P = 0.012) with an odds ratio of 25 [2.52; 105]. Of the five patients treated with antivitamin K, three presented a definitive amaurosis; the first one was relayed by low-molecularweight heparin and operated five days after symptoms appeared; the second one was operated six hours after symptom appearance and after antagonism of antivitamin K; and the last one was not operated and antivitamin K was continued. One patient treated with antivitamin K was operated four hours after the onset of symptoms and antivitamin K discontinuation and recovered without any complication. The last patient treated with antivitamin K benefited from medical treatment and antivitamin K interruption and presented permanent oculomotor dysfunction. The patient treated with dual antiplatelet was operated two days after symptoms appeared but presented a definitive amaurosis.
Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004
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4. Discussion Twenty-five cases of orbital haematomas were included in this study, constituting, to our knowledge, the greatest series available in the literature. Our study highlights the wide heterogeneity of the cases and the lack of standardised treatment. The management of antithrombotics definitely needs to be outlined, because they have a major impact on the functional prognosis. Huebert [6] retrospectively assessed 160,000 cases of retrobulbar or peribulbar anaesthesia and emphasised that anticoagulant or dual antiplatelet treatments were involved in all the cases of retrobulbar haematomas. In our study, five patients were treated with antivitamin K, and one was treated with dual antiplatelet. Despite a limited number of patients under antithrombotic therapy and a more advanced age, their prognosis was worse compared to patients without antithrombotic, which has already been demonstrated in other pathologies such as intracranial haemorrhage [7]. Surgery was not initially recommended for these patients regarding the risk of haemorrhage and worsening of the underlying condition. In our study, surgery was performed in 84% of the cases. Nevertheless, surgery was most frequently proposed for patients without antithrombotic treatment, probably due to the fear of haemorrhagic recurrence. Different techniques were used and could be associated. Haematoma evacuation was the most-used technique, allowing a regression of the orbital pressure. It was particularly effective and safe in the case of subperiosteal haematoma. With regard to retrobulbar haematoma, an intraconal dissection was necessary and increased the risk of ophthalmic nerve damage and retrobulbar haemorrhage recurrence, especially for patients treated with antithrombotics. Orbital bone decompression also led to a diminution of the orbital pressure. This technique avoided intraconal dissection, but could be responsible for ocular motility troubles and diplopia. It also exposed the patient to the risk of haemorrhage by infraorbital artery damage. Lateral canthotomy with inferior cantholysis was the least-used technique despite its ability to diminish orbital pressure, wherever the localisation of the haematoma [8,9]. It could be performed under local anaesthesia and avoided any intraorbital dissection, thus decreasing the risk of haemorrhage for patients treated with antithrombotics. In our study, haematoma evacuation did not show better results. Indeed, this procedure was performed on three patients treated with antithrombotics, two of them presenting finally with permanent amaurosis. The risk of haemorrhage recurrence due to the intraconal dissection in patients treated with antithrombotics has led us to recommend lateral canthotomy and inferior cantholysis. Only two patients treated with antithrombotics were operated on the day of the occurrence of the haematoma. One of them recovered without aftereffect. The other patients treated with antithrombotics operated after this delay presented with permanent amaurosis. Delayed surgery of orbital haematomas extended the optic nerve compression and increased the risk of sequelae [10]. Therefore, we advise performing surgery as soon as possible even if the patients are treated with antithrombotics. Medical treatment is based on corticosteroids and osmotic diuretics such as mannitol or carbonic anhydrase inhibitor as acetazolamide. Medical treatment needs to be introduced as soon as possible without delaying surgical treatment [2,8,11–14]. In our study, medical treatment was rarely prescribed, and only 11 patients (44%) benefited from medical treatment, including the four patients who had not been operated. Medical treatment
3
was, rather, proposed for patients treated with antithrombotics probably because they had had less surgery or had a longer delay. Two patients treated with medical therapy alone recovered without sequelae. They presented initially a stable decrease of visual acuity and recovered quickly after onset of systemic corticosteroids. The attitude regarding antithrombotic treatment was adapted for each case. Antagonism with prothrombin complex concentrate was not proposed by any medical team. The French guidelines (HAS) specify that in cases of bleeding that compromise a functional prognosis, antivitamin K can be stopped, combined with an antagonism of 10 mg vitamin K and prothrombin complex concentrate (adapted to the INR) to obtain an INR inferior to 1.5. The restricted number of patients in our study prevented us from proposing an effective management. Currently, each case should be assessed and discussed, with the thrombotic risk of the patient on the one hand and the functional impact of decreased visual acuity or even blindness, depending on the visual acuity of the contralateral eye, on the other hand. 5. Conclusion In our 25-patient series, antithrombotics appear to worsen the functional prognosis of orbital haematomas. The surgical delay must be shortened as much as possible, reducing the duration of the optic nerve’s damage and thus the risk of sequelae. The surgical management of orbital haematoma in patients treated with antithrombotics is not contraindicated. A lateral canthotomy with inferior cantholysis could be an appropriate solution, decreasing the risk of sequelae related to an untreated haematoma without increasing the risk of iatrogenic orbital haemorrhage recurrence. Evacuation of subperiosteal haematomas can also be carried out. A medical treatment combining corticosteroids and diuretics, also needs to be urgently established. Discontinuation of the antithrombotic treatment and potential antagonism will be discussed specifically for each case. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements The authors thank the centres that participated in the study.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.jormas.2018.05. 004. References [1] Landa MS, Landa EH, Levine MR. Subperiosteal hematoma of the orbit: case presentation. Ophthal Plast Reconstr Surg 1998;14:189–92. [2] Chen YA, Singhal D, Chen YR, et al. Management of acute traumatic retrobulbar haematomas: a 10-year retrospective review. J Plast Reconstr Aesthetic Surg JPRAS 2012;65:1325–30. http://dx.doi.org/10.1016/j.bjps.2012.04.037. [3] da Costa Jr LB, de Andrade A, Henriques JG, de B, et al. Traumatic bilateral intraorbital (subperiosteal) hematoma associated with epidural hematoma: case report. Arq Neuropsiquiatr 2003;61:1039–41. [4] Guyot L, Thiery G, Salles F, et al. Post-operative orbital haematomas over a 12-year period. A description of three cases among 280 orbital procedures. J. Cranio-Maxillo-fac Surg 2013;41:794–6. http://dx.doi.org/10.1016/j.jcms. 2013.01.028. [5] Dareau S, Gros T, Bassoul B, et al. [Orbital haemorrhage after medial canthus episclera (sub-Tenon’s) anaesthesia] in French. Ann Fr Anesthe´sie Re´animation 2003;22:474–6.
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[6] Huebert I, Heinicke N, Kook D, et al. Dual platelet inhibition in cases of severe retrobulbar hemorrhage following retrobulbar and peribulbar anesthesia. J. Cataract Refract Surg 2015;41:2092–101. http://dx.doi.org/10.1016/j.jcrs. 2015.10.051. [7] Ray B, Keyrouz SG. Management of anticoagulant-related intracranial hemorrhage: an evidence-based review. Crit Care 2014;18:223. http://dx.doi.org/ 10.1186/cc13889. [8] Colletti G, Valassina D, Rabbiosi D, et al. Traumatic and iatrogenic retrobulbar hemorrhage: an 8-patient series. J Oral Maxillofac Surg 2012;70:464–8. http:// dx.doi.org/10.1016/j.joms.2012.05.007. [9] Patel AD, Alford M, Carter KD. Persistent visual loss following retrobulbar hemorrhage. Can J Ophthalmol 2002;37:34–6. [10] Lima V, Burt B, Leibovitch I, et al. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol 2009;54:441–9. http:// dx.doi.org/10.1016/j.survophthal.2009.04.005.
[11] Gerbino G, Ramieri GA, Nasi A. Diagnosis and treatment of retrobulbar haematomas following blunt orbital trauma: a description of eight cases. Int J Oral Maxillofac Surg 2005;34:127–31. http://dx.doi.org/10.1016/j.ijom. 2004.05.001. [12] Hislop WS, Dutton GN. Retrobulbar haemorrhage: can blindness be prevented? Injury 1994;25:663–5. [13] Popat H, Doyle PT, Davies SJ. Blindness following retrobulbar haemorrhage-it can be prevented. Br J Oral Maxillofac Surg 2007;45:163–4. http://dx.doi.org/ 10.1016/j.bjoms.2005.06.028. [14] Soare S, Foletti J-M, Gallucci A, et al. Update on orbital decompression as emergency treatment of traumatic blindness. J Cranio-Maxillofac Surg 2015;43:1000–3. http://dx.doi.org/10.1016/j.jcms.2015.05.003.
Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004
JORMAS-189; No. of Pages 4 J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Impact of antithrombotic treatment in orbital haematoma N. Graillon a,*, J.M. Foletti a, M.K. Le Roux a, M. Alessandrini b, M. Benzaquen a, L. Guyot a a b
Oral and Maxillofacial surgery department, North hospital, assistance publique hoˆpitaux de Marseille, chemin des Bourrely, 13915 Marseille cedex 20, France Aix Marseille Universite´, SPMC EA 3279, 27, boulevard Jean-Moulin, 13385 Marseille, France
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 January 2018 Accepted 11 May 2018
Introduction: Orbital haematomas threaten the visual prognosis, but no treatment guidelines have been proposed. Antithrombotics could affect their prognosis and treatment. This study aimed to evaluate the effect of antithrombotics in the management of orbital haematomas and to suggest a standardised protocol. Material and methods: We conducted a retrospective study by sending a standardised questionnaire to 20 French maxillofacial surgery university departments to collect all the cases of orbital haematoma. Results: Twenty-five cases from 10 centres were collected, including five patients treated with anticoagulant and one patient treated with dual antiplatelet. Antithrombotics increased the risk of amaurosis and ocular disorders significantly. Surgery was performed for 66.7% of patients treated with antithrombotic and for 89.5% of other patients. Surgical delay was longer in patients treated with antithrombotic. Surgical drainage was used in most of the cases, whereas canthotomy with inferior cantholysis was the least-used technique. Conclusion: Antithrombotics appear to worsen the functional prognosis of orbital haematomas. A surgical management of orbital haematoma in patients treated with antithrombotics is not contraindicated. Surgical delay must be shortened as much as possible. A lateral canthotomy with inferior cantholysis seems to be an appropriate solution.
C 2018 Elsevier Masson SAS. All rights reserved.
Keywords: Orbital haematoma Orbital surgery Antithrombotic Anticoagulant
1. Introduction Orbital haematoma is a rare condition that can threaten the visual prognosis. Two localisations have been emphasised: subperiosteal and intraorbital, the latest being located either in intra- or extraconal space [1]. Orbital haematoma mainly occurs after middle-face trauma, surgical reduction of orbital and zygomatic fractures, orbital and eyelid surgery [2–4], endoscopic sinus surgery [2] or retrobulbar injections [5]. They can also develop spontaneously or after a minor trauma, all the more so if combined with antithrombotic drugs. Older people are more exposed to orbital haematoma [2] from their specific comorbidities (stroke with antithrombotic prescription, collapse). Due to the ageing of the population, more and more bleeding complications will be noticed after facial trauma, and appropriate protocols should be established for optimal care. Because orbital haematomas are very rare, no treatment guidelines have been proposed yet [2]. Surgical treatment is not always the best available option. Orbital
* Corresponding author. Service de chirurgie maxillo-faciale et stomatologie hoˆpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France. E-mail address: [email protected] (N. Graillon).
haematoma evacuation may lead to a significant worsening of visual function, especially for intraconal localisation and when antithrombotic drugs are involved. This study aimed to evaluate the effect of antithrombotic drugs (anticoagulant and antiplatelet) in the management of orbital haematomas in France and to suggest a standardised protocol. 2. Material and method We conducted a retrospective study from June 2013 to June 2016 by sending a standardised questionnaire to 20 French maxillofacial surgery university departments (Appendix A). We collected all the cases of orbital haematoma and analysed the data regarding management and treatment. For each case, background, symptomatology, diagnosis, treatment and evolution of the patient were noted on the questionnaire. Some items specifically focused on antithrombotics and their management. Patients were divided in two groups: group 1 for patients treated with antithrombotic drugs (ATT) and group 2 for patients without antithrombotic drugs (NoATT). Haematomas were classified into three localisations: retrobulbar (intraconal) when the haematoma was located in the cone constituted by the extraocular muscles, extraconal when the
https://doi.org/10.1016/j.jormas.2018.05.004 C 2018 Elsevier Masson SAS. All rights reserved. 2468-7855/
Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004
G Model
JORMAS-189; No. of Pages 4 N. Graillon et al. / J Stomatol Oral Maxillofac Surg xxx (2018) xxx–xxx
2
haematoma was located in the periorbita outside the cone constituted by the extraocular muscles and subperiosteal when the haematoma was located outside the periorbita. 2.1. Ethical considerations This study was conducted in accordance with the principles of the Helsinki Declaration (2013). 2.2. Statistical analysis For descriptive analyses of the sample characteristics, data were expressed as proportions for the qualitative variables and as the means, standard deviations, median and interquartile range (IQR) for continuous variables. Comparisons between groups with and without anticoagulant treatment within the sample were evaluated using nonparametric Mann–Whitney tests for the continuous variable and using Chi-square or Fisher’s exact tests for qualitative variables with odds ratios (OR) and their 95% confidence intervals (95% CI), estimated using the bootstrap method (n = 1000 samples) to assess the degree of associations. All the tests were two-sided, and statistical significance was defined as P0.05. The statistical analyses were performed using the SPSS version 17.0.2 software package (SPSS Inc., Chicago, IL, USA).
3. Results Twenty-five cases from 10 centres, 15 men (60%) and 10 women (40%), were collected. Results are summarised in Table 1. Patients were divided in group 1 (antithrombotic treatment, n = 6) and group 2 (no antithrombotic treatment, n = 19). Five patients were treated with anticoagulant therapy such as antivitamin K, with one overdosed (international normalised ratio [INR] = 7). One patient was treated with dual antiplatelet (acetylsalicylic acid + clopidogrel). The average age of patients was 50 years. Patients treated with antithrombotics (group 1) were significantly older than other patients (group 2) (P = 0.0017). Table 1 Comparison of characteristics of the patients treated with antithrombotics (group 1) and without antithrombotics (group 2).
Age (years) Effect ifs (n) Aetiologies Traumatic Postoperative Others Localisations Retrobulbar Extraconal Subperiosteal Medical treatment Surgical treatment including Lateral canthotomy with inferior cantholysis Orbital bone decompression Evacuation Approach reopening Surgical delay 6h >6h Sequelae Amaurosis Visual acuity decrease Oculomotor disorders None
Antithrombotics (group 1)
Non-antithrombotics (group 2)
80.4 6 (5 AVK, 1 DAP)
41.9 19
83.3% 0 16.7%
63.2% 31.6% 5.3%
66.7% 33.3% 0 66.7% 66.7% 15%
31.6% 31.6% 36.8% 36.8% 89.5% 17.6%
50% 75% 0
29.4% 70.6% 35.3%
33% 33%
57.8% 26.3%
66.7% 0 33.3% 16.7%
5.3% 10.5% 5.3% 73.7%
Facial trauma was the most frequent cause (68%) of orbital haematoma, with seven orbital floor fractures, two zygoma fractures, one orbital roof fracture, one sphenoidal fracture and one case of facial trauma without any fracture. We noted one case of spontaneous haematoma in group 1 (ATT) without antithrombotic overdose. Six patients in group 2 (NoATT) presented a postoperative haematoma, complicating four reductions of orbital floor fracture, one reduction of zygoma fracture and one bone orbital decompression in Grave’s disease. One case was due to a barotrauma in scuba diving. Three patients in group 1 (NoATT) presented hypertension versus 2 patients in group 2 (NoATT). No other coagulation disease was found. A facial bone CT scan was performed for 21 patients. Four patients presented a suggestive symptomatology after orbital surgery and were directly transferred to the operating room without any imaging. Localisation was most frequently retrobulbar (four patients) in group 1 (ATT). Two patients presented an extraconal localisation in group 1 (ATT). The repartition was different in group 2 (NoATT), with seven subperiosteal haematomas, six retrobulbar haematomas and six extraconal haematomas. Medical treatment was prescribed for four patients (66.7%) in group 1 (ATT) and for seven patients (36.8%) in group 2 (NoATT). Surgery was performed on four patients (66.7%) in group 1 (ATT) and 17 patients (89.5%) in group 2 (NoATT). Surgical drainage was used in most of the cases, whereas canthotomy with inferior cantholysis was the least-used technique. Surgical delay was longer in patients of group 1 (ATT). Two patients in this group were operated on the day of the occurrence of the haematoma, four hours and six hours after the symptoms occurred. Another patient of group 1 (ATT) was operated two days later, and the last one was operated five days later. In group 2 (NoATT), 15 patients were operated within eight hours after the onset of symptoms. Two patients were operated after this delay. The first one was operated five days after the appearance of the symptoms because he did not consult before, and the second one was operated 22 days after the appearance of the symptoms, due to a poor initial neurological prognosis. Antivitamin K was prescribed for one nonsurgical patient, relayed by low-molecular-weight heparin for one patient and stopped for three patients, including the overdosed patient. This patient received vitamin K. The patient treated with dual antiplatelet was switched to aspirin. Five patients (83; 3%) in group 1 (ATT) presented permanent aftereffects due to orbital haematoma, versus three patients (26.3%) in group 2 (NoATT). Amaurosis was the most frequent complication in group 1, present in 66.7% of the cases (4 patients) versus 5.3% (1 patient) in group 2. Antithrombotics increased the risk of amaurosis (P = 0.005) significantly, with an odds ratio of 34 [3; 96], and the risk of ocular disorders (P = 0.035) with an odds ratio of 17 [1.6; 85]. In total, antithrombotics significantly reduced the recovery of visual acuity (P = 0.012) with an odds ratio of 25 [2.52; 105]. Of the five patients treated with antivitamin K, three presented a definitive amaurosis; the first one was relayed by low-molecularweight heparin and operated five days after symptoms appeared; the second one was operated six hours after symptom appearance and after antagonism of antivitamin K; and the last one was not operated and antivitamin K was continued. One patient treated with antivitamin K was operated four hours after the onset of symptoms and antivitamin K discontinuation and recovered without any complication. The last patient treated with antivitamin K benefited from medical treatment and antivitamin K interruption and presented permanent oculomotor dysfunction. The patient treated with dual antiplatelet was operated two days after symptoms appeared but presented a definitive amaurosis.
Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004
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4. Discussion Twenty-five cases of orbital haematomas were included in this study, constituting, to our knowledge, the greatest series available in the literature. Our study highlights the wide heterogeneity of the cases and the lack of standardised treatment. The management of antithrombotics definitely needs to be outlined, because they have a major impact on the functional prognosis. Huebert [6] retrospectively assessed 160,000 cases of retrobulbar or peribulbar anaesthesia and emphasised that anticoagulant or dual antiplatelet treatments were involved in all the cases of retrobulbar haematomas. In our study, five patients were treated with antivitamin K, and one was treated with dual antiplatelet. Despite a limited number of patients under antithrombotic therapy and a more advanced age, their prognosis was worse compared to patients without antithrombotic, which has already been demonstrated in other pathologies such as intracranial haemorrhage [7]. Surgery was not initially recommended for these patients regarding the risk of haemorrhage and worsening of the underlying condition. In our study, surgery was performed in 84% of the cases. Nevertheless, surgery was most frequently proposed for patients without antithrombotic treatment, probably due to the fear of haemorrhagic recurrence. Different techniques were used and could be associated. Haematoma evacuation was the most-used technique, allowing a regression of the orbital pressure. It was particularly effective and safe in the case of subperiosteal haematoma. With regard to retrobulbar haematoma, an intraconal dissection was necessary and increased the risk of ophthalmic nerve damage and retrobulbar haemorrhage recurrence, especially for patients treated with antithrombotics. Orbital bone decompression also led to a diminution of the orbital pressure. This technique avoided intraconal dissection, but could be responsible for ocular motility troubles and diplopia. It also exposed the patient to the risk of haemorrhage by infraorbital artery damage. Lateral canthotomy with inferior cantholysis was the least-used technique despite its ability to diminish orbital pressure, wherever the localisation of the haematoma [8,9]. It could be performed under local anaesthesia and avoided any intraorbital dissection, thus decreasing the risk of haemorrhage for patients treated with antithrombotics. In our study, haematoma evacuation did not show better results. Indeed, this procedure was performed on three patients treated with antithrombotics, two of them presenting finally with permanent amaurosis. The risk of haemorrhage recurrence due to the intraconal dissection in patients treated with antithrombotics has led us to recommend lateral canthotomy and inferior cantholysis. Only two patients treated with antithrombotics were operated on the day of the occurrence of the haematoma. One of them recovered without aftereffect. The other patients treated with antithrombotics operated after this delay presented with permanent amaurosis. Delayed surgery of orbital haematomas extended the optic nerve compression and increased the risk of sequelae [10]. Therefore, we advise performing surgery as soon as possible even if the patients are treated with antithrombotics. Medical treatment is based on corticosteroids and osmotic diuretics such as mannitol or carbonic anhydrase inhibitor as acetazolamide. Medical treatment needs to be introduced as soon as possible without delaying surgical treatment [2,8,11–14]. In our study, medical treatment was rarely prescribed, and only 11 patients (44%) benefited from medical treatment, including the four patients who had not been operated. Medical treatment
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was, rather, proposed for patients treated with antithrombotics probably because they had had less surgery or had a longer delay. Two patients treated with medical therapy alone recovered without sequelae. They presented initially a stable decrease of visual acuity and recovered quickly after onset of systemic corticosteroids. The attitude regarding antithrombotic treatment was adapted for each case. Antagonism with prothrombin complex concentrate was not proposed by any medical team. The French guidelines (HAS) specify that in cases of bleeding that compromise a functional prognosis, antivitamin K can be stopped, combined with an antagonism of 10 mg vitamin K and prothrombin complex concentrate (adapted to the INR) to obtain an INR inferior to 1.5. The restricted number of patients in our study prevented us from proposing an effective management. Currently, each case should be assessed and discussed, with the thrombotic risk of the patient on the one hand and the functional impact of decreased visual acuity or even blindness, depending on the visual acuity of the contralateral eye, on the other hand. 5. Conclusion In our 25-patient series, antithrombotics appear to worsen the functional prognosis of orbital haematomas. The surgical delay must be shortened as much as possible, reducing the duration of the optic nerve’s damage and thus the risk of sequelae. The surgical management of orbital haematoma in patients treated with antithrombotics is not contraindicated. A lateral canthotomy with inferior cantholysis could be an appropriate solution, decreasing the risk of sequelae related to an untreated haematoma without increasing the risk of iatrogenic orbital haemorrhage recurrence. Evacuation of subperiosteal haematomas can also be carried out. A medical treatment combining corticosteroids and diuretics, also needs to be urgently established. Discontinuation of the antithrombotic treatment and potential antagonism will be discussed specifically for each case. Disclosure of interest The authors declare that they have no competing interest. Acknowledgements The authors thank the centres that participated in the study.
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Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004
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Please cite this article in press as: Graillon N, et al. Impact of antithrombotic treatment in orbital haematoma. J Stomatol Oral Maxillofac Surg (2018), https://doi.org/10.1016/j.jormas.2018.05.004