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Post-traumatic eye observations
British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Post-traumatic eye observations M.C. Bater ∗ , P.L. Ramchandani, P.A. Brennan Maxillofacial Unit, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, UK Received 26 August 2004; accepted 4 February 2005 Available online 6 May 2005
Abstract Retrobulbar haemorrhage after facial trauma or surgery is an uncommon but well-documented complication. The assessment and management of this condition is variable. We asked 288 maxillofacial surgeons in the UK about the signs and symptoms, incidence, and management of retrobulbar haemorrhage. We also enquired about the regimen that they used for eye observations, the patients who, in their opinion, required observation, and the method of communication of instructions to the nursing staff. A total of 185 responded (64%). Each surgeon had seen a mean of 1.3 cases of retrobulbar haemorrhage, of which most, n = 190 (91%) were treated by surgery. There were 96 different eye observations regimens documented. There was a general consensus about the signs and symptoms, and 82 (44%) of respondents used a proforma for recording eye observations. On the basis of this study we recommend a standard regimen for eye observations, and have a designed a facial injury advice sheet to be given to patients who attend the accident and emergency department and are to be discharged home and followed up at a later date. © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Retrobulbar haemorrhage; Post-traumatic eye observations; Zygomatic complex fractures
Introduction Retrobulbar haemorrhage is a rare complication of injury or operation near the orbit (Fig. 1), and blindness may be permanent if the condition is not diagnosed and treated early. Oral and maxillofacial surgeons are regularly referred patients with injuries around the orbit, and as a consequence we should ensure that all members of our team recognise this condition immediately and manage it with minimal morbidity. Protocols for the management of orbital trauma in patients presenting to accident and emergency departments have been described,1 as has a scheme of eye observations for use by the nursing staff in “at-risk” inpatients.2 It was our impression that while eye observations were being undertaken in some patients with midfacial trauma, the frequency of, and indications for, their use varied. We there-
∗
Corresponding author. Present address: Flat 10 Banister Court, 71 Northlands Road, Southampton SO15 2QR, UK. Tel.: +44 2392 433024. E-mail address: [email protected] (M.C. Bater).
fore used a questionnaire to investigate the current practice of consultant maxillofacial surgeons in the UK, with particular reference to retrobulbar haemorrhage (Appendix A). We also wanted to see whether we could establish a standard frequency and duration for the use of eye observations in patients who had had injuries or operations around the orbit. Our final aim was to make sure that patients who presented to accident and emergency departments with facial injuries and were discharged home to be followed up at a later date were issued with appropriate advice and instruction for the time between appointments. We designed a facial injury advice sheet for this purpose (Appendix B).
Method An anonymised postal questionnaire survey was undertaken of all 288 consultant oral and maxillofacial surgeons in the UK who were registered as fellows of the British Association of Oral and Maxillofacial Surgeons. We asked questions
0266-4356/$ – see front matter © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2005.02.002
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
411
Table 1 Ocular symptoms (a) and signs (b) looked for following zygomatic or orbital injury (a) Symptoms Pain Reduced visual acuity Diplopia Cheek paraesthesia
180 (97%) 183 (99%) 80 (43%) 28 (15%)
(b) Signs Proptosis Tense globe Subconjunctival oedema Loss of direct papillary reflex
178 (96%) 135 (73%) 37 (20%) 165 (89%)
Data are number (%) of respondents.
Fig. 1. Severe penetrating injury that resulted in a retrobulbar haemorrhage.
about the signs and symptoms, and experience and management of retrobulbar haemorrhage. We also asked about the eye observation regimen that they utilised, what type of patient required observation, and the method of communication of instructions to the nursing staff. Surgeons were also questioned about whether the consent form included a warning about possible loss of vision in patients who were about to have surgery in and around the orbit. A pre-paid envelope was included and, as the questionnaire was anonymous, no reminders were sent.
operation note. A proforma was used routinely for recording eye observations by 81 respondents (44%). Overall, 134 respondents (72%) wrote that they had had experience of 231 cases of retrobulbar haemorrhage. This is a mean of 1.3 cases per surgeon that replied. Of the 231 cases, only 209 recorded details of how they were managed. These included 190 (91%) episodes of retrobulbar haemorrhage treated by surgery alone or a combination of medical and surgical treatment. Medical treatment (which was the only treatment given by 19 surgeons (9%)) was with mannitol, acetazolamide, and steroids. With further regards to the 190 cases treated by surgery, 149 further detailed the procedure undertaken. Of these the single most quoted treatment was lateral canthotomy and cantholysis (n = 47, 32%). Just over half of these surgeons (n = 77, 52%) referred to a decompression procedure.
Results There were 185 replies, (a response rate of 64%). One hundred respondents (54%) routinely recorded the possibility of loss of vision on a consent form for patients who were to be operated on for orbito-zygomatic injuries. Eighty-three surgeons (45%) required observations to be made on patients who presented initially with periorbital fractures, and all but five (3%) advocated them in patients who had undergone surgery on these structures. Concerning signs and symptoms that are routinely recorded, at least 178 surgeons (96%) would record pain, decreasing visual acuity, and proptosis. Diplopia was thought to be less important, being recorded by 80 surgeons (43%). Most surgeons considered a tense globe (n = 135, 73%) and loss of pupillary reflex (n = 165, 89%) as important features of retrobulbar haemorrhage. Only 37 (20%) would look for subconjunctival oedema, and a minority (n = 28, 15%) would record paraesthesia on the cheek (Table 1). Of the 185 replies, there were 96 different regimens of eye observation. One hundred and twenty four surgeons (67%) wrote that they would communicate the use of eye observations to the nursing staff verbally, and 155 (84%) would record the frequency and duration of eye observations in the
Discussion Although retrobulbar haemorrhage is rare, over 70% of the respondents in this survey had encountered it. Ord reported a large series of fractures of the zygomatic complex, and found an incidence of postoperative retrobulbar haemorrhage of 0.3%.3 Retrobulbar haemorrhage has been reported to occur three days after a zygomatic fracture and up to seven days after severe head injury.4,5 There was a consensus about signs and symptoms of retrobulbar haemorrhage, including pain, proptosis, and reduced visual acuity. With regard to management, once again there was considerable agreement. Although medical treatment alone has been reported to be successful in its management,6 it was undertaken in only 19 out of 209 (9%) cases of retrobulbar haemorrhage where the management was described. In accordance with currently accepted practice,7 medical treatment to “buy” time until a definitive surgical procedure could be performed was undertaken in 106 (51%) of the cases detailed. There were 96 different regimens of eye observations, of which only 27 out of 96 (28%) were routinely used by more than one respondent. We therefore devised a regimen that was
412
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Table 2 Recommended regimen for eye observations Frequency
Duration
Every 15 min Every 30 min Hourly
2h 2h 16 h or overnight
most likely to identify a developing retrobulbar haemorrhage (Table 2). As most of these episodes have been reported to occur overnight, the patient awakening with loss of vision,3,8 we think that hourly eye observations throughout the night are important. Although there will inevitably be individual variations or deviations from this type of protocol, we think that it is a distillation of current practice, being safe for preservation of sight, and making the best use of nursing time. The early diagnosis of retrobulbar haemorrhage is essential as vision may be preserved if intervention is prompt.9 Irreversible damage to retinal cells is thought to occur only after 100 min of ischaemia.10 It is therefore important that
other members of the team are aware of their role in the early recognition of this condition. With this is mind most surgeons would either record their requirements for eye observations in the operation note, or inform the nursing staff directly (presumably through the junior medical staff). Somewhat surprisingly only 44% of surgeons used a proforma for recording eye observations. In our unit we use the orbital observation chart first described by Hayter and Sugar.2 With the ever increasing reduction in hours worked by junior doctors, the recognition and initial management of retrobulbar haemorrage is all the more important, both for junior maxillofacial trainees and for other trainees who may see this condition (accident and emergency medical staff). Adequate explanation to patients who are discharged home of the possibility of this condition, and the likely symptoms, is equally important not only for vision, but also from a medicolegal perspective. As a result of this study, we have produced an advice sheet, which is given to patients who have been discharged, detailing the procedure to follow should their vision deteriorate (Appendix B).
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Appendix A. Questionnaire
413
414
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Appendix B. Facial injury advice sheet
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
415
416
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
References 1. Hislop WS, Dutton GN, Douglas PS. Treatment of retrobulbar haemorrhage in accident and emergency departments. Br J Oral Maxillofac Surg 1996;34:289–92. 2. Hayter JP, Sugar A. An orbital observation chart. Br J Oral Maxillofac Surg 1991;29:77–9. 3. Ord RA. Postoperative retrobulbar haemorrhage and blindness complicating trauma surgery. Br J Oral Surg 1981;19:202–7. 4. Morris TA, Ward-Booth RP. Delayed spontaneous retrobulbar haemorrhage—a case report. J Maxillofac Surg 1985;13:129–30. 5. Ghufoor K, Sandhu G, Sutcliffe J. Delayed onset of retrobulbar haemorrhage following severe head injury: a case report and review. Injury 1998;29:139–41.
6. Wood CM. The medical management of retrobulbar haemorrhage complicating facial fractures: a case report. Br J Oral Maxillofac Surg 1989;27:291–5. 7. Bailey WK, Kuo PC, Evans LS. Diagnosis and treatment of retrobulbar haemorrhage. J Oral Maxillofac Surg 1993;51:780–2. 8. Hislop WS, Dutton GN. Retrobulbar haemorrhage: can blindness be prevented? Injury 1994;25:663–5. 9. Heinze JB, Hueston JT. Blindness after blepharoplasty: mechanism and early reversal. Plast Reconstr Surg 1978;61:347–54. 10. Hayreh SS, Kolder HE, Weingeist TA. Central retinal occlusion and retinal tolerance time. Ophthalmology 1980;87:75–8.
Post-traumatic eye observations M.C. Bater ∗ , P.L. Ramchandani, P.A. Brennan Maxillofacial Unit, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, UK Received 26 August 2004; accepted 4 February 2005 Available online 6 May 2005
Abstract Retrobulbar haemorrhage after facial trauma or surgery is an uncommon but well-documented complication. The assessment and management of this condition is variable. We asked 288 maxillofacial surgeons in the UK about the signs and symptoms, incidence, and management of retrobulbar haemorrhage. We also enquired about the regimen that they used for eye observations, the patients who, in their opinion, required observation, and the method of communication of instructions to the nursing staff. A total of 185 responded (64%). Each surgeon had seen a mean of 1.3 cases of retrobulbar haemorrhage, of which most, n = 190 (91%) were treated by surgery. There were 96 different eye observations regimens documented. There was a general consensus about the signs and symptoms, and 82 (44%) of respondents used a proforma for recording eye observations. On the basis of this study we recommend a standard regimen for eye observations, and have a designed a facial injury advice sheet to be given to patients who attend the accident and emergency department and are to be discharged home and followed up at a later date. © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Retrobulbar haemorrhage; Post-traumatic eye observations; Zygomatic complex fractures
Introduction Retrobulbar haemorrhage is a rare complication of injury or operation near the orbit (Fig. 1), and blindness may be permanent if the condition is not diagnosed and treated early. Oral and maxillofacial surgeons are regularly referred patients with injuries around the orbit, and as a consequence we should ensure that all members of our team recognise this condition immediately and manage it with minimal morbidity. Protocols for the management of orbital trauma in patients presenting to accident and emergency departments have been described,1 as has a scheme of eye observations for use by the nursing staff in “at-risk” inpatients.2 It was our impression that while eye observations were being undertaken in some patients with midfacial trauma, the frequency of, and indications for, their use varied. We there-
∗
Corresponding author. Present address: Flat 10 Banister Court, 71 Northlands Road, Southampton SO15 2QR, UK. Tel.: +44 2392 433024. E-mail address: [email protected] (M.C. Bater).
fore used a questionnaire to investigate the current practice of consultant maxillofacial surgeons in the UK, with particular reference to retrobulbar haemorrhage (Appendix A). We also wanted to see whether we could establish a standard frequency and duration for the use of eye observations in patients who had had injuries or operations around the orbit. Our final aim was to make sure that patients who presented to accident and emergency departments with facial injuries and were discharged home to be followed up at a later date were issued with appropriate advice and instruction for the time between appointments. We designed a facial injury advice sheet for this purpose (Appendix B).
Method An anonymised postal questionnaire survey was undertaken of all 288 consultant oral and maxillofacial surgeons in the UK who were registered as fellows of the British Association of Oral and Maxillofacial Surgeons. We asked questions
0266-4356/$ – see front matter © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjoms.2005.02.002
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
411
Table 1 Ocular symptoms (a) and signs (b) looked for following zygomatic or orbital injury (a) Symptoms Pain Reduced visual acuity Diplopia Cheek paraesthesia
180 (97%) 183 (99%) 80 (43%) 28 (15%)
(b) Signs Proptosis Tense globe Subconjunctival oedema Loss of direct papillary reflex
178 (96%) 135 (73%) 37 (20%) 165 (89%)
Data are number (%) of respondents.
Fig. 1. Severe penetrating injury that resulted in a retrobulbar haemorrhage.
about the signs and symptoms, and experience and management of retrobulbar haemorrhage. We also asked about the eye observation regimen that they utilised, what type of patient required observation, and the method of communication of instructions to the nursing staff. Surgeons were also questioned about whether the consent form included a warning about possible loss of vision in patients who were about to have surgery in and around the orbit. A pre-paid envelope was included and, as the questionnaire was anonymous, no reminders were sent.
operation note. A proforma was used routinely for recording eye observations by 81 respondents (44%). Overall, 134 respondents (72%) wrote that they had had experience of 231 cases of retrobulbar haemorrhage. This is a mean of 1.3 cases per surgeon that replied. Of the 231 cases, only 209 recorded details of how they were managed. These included 190 (91%) episodes of retrobulbar haemorrhage treated by surgery alone or a combination of medical and surgical treatment. Medical treatment (which was the only treatment given by 19 surgeons (9%)) was with mannitol, acetazolamide, and steroids. With further regards to the 190 cases treated by surgery, 149 further detailed the procedure undertaken. Of these the single most quoted treatment was lateral canthotomy and cantholysis (n = 47, 32%). Just over half of these surgeons (n = 77, 52%) referred to a decompression procedure.
Results There were 185 replies, (a response rate of 64%). One hundred respondents (54%) routinely recorded the possibility of loss of vision on a consent form for patients who were to be operated on for orbito-zygomatic injuries. Eighty-three surgeons (45%) required observations to be made on patients who presented initially with periorbital fractures, and all but five (3%) advocated them in patients who had undergone surgery on these structures. Concerning signs and symptoms that are routinely recorded, at least 178 surgeons (96%) would record pain, decreasing visual acuity, and proptosis. Diplopia was thought to be less important, being recorded by 80 surgeons (43%). Most surgeons considered a tense globe (n = 135, 73%) and loss of pupillary reflex (n = 165, 89%) as important features of retrobulbar haemorrhage. Only 37 (20%) would look for subconjunctival oedema, and a minority (n = 28, 15%) would record paraesthesia on the cheek (Table 1). Of the 185 replies, there were 96 different regimens of eye observation. One hundred and twenty four surgeons (67%) wrote that they would communicate the use of eye observations to the nursing staff verbally, and 155 (84%) would record the frequency and duration of eye observations in the
Discussion Although retrobulbar haemorrhage is rare, over 70% of the respondents in this survey had encountered it. Ord reported a large series of fractures of the zygomatic complex, and found an incidence of postoperative retrobulbar haemorrhage of 0.3%.3 Retrobulbar haemorrhage has been reported to occur three days after a zygomatic fracture and up to seven days after severe head injury.4,5 There was a consensus about signs and symptoms of retrobulbar haemorrhage, including pain, proptosis, and reduced visual acuity. With regard to management, once again there was considerable agreement. Although medical treatment alone has been reported to be successful in its management,6 it was undertaken in only 19 out of 209 (9%) cases of retrobulbar haemorrhage where the management was described. In accordance with currently accepted practice,7 medical treatment to “buy” time until a definitive surgical procedure could be performed was undertaken in 106 (51%) of the cases detailed. There were 96 different regimens of eye observations, of which only 27 out of 96 (28%) were routinely used by more than one respondent. We therefore devised a regimen that was
412
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Table 2 Recommended regimen for eye observations Frequency
Duration
Every 15 min Every 30 min Hourly
2h 2h 16 h or overnight
most likely to identify a developing retrobulbar haemorrhage (Table 2). As most of these episodes have been reported to occur overnight, the patient awakening with loss of vision,3,8 we think that hourly eye observations throughout the night are important. Although there will inevitably be individual variations or deviations from this type of protocol, we think that it is a distillation of current practice, being safe for preservation of sight, and making the best use of nursing time. The early diagnosis of retrobulbar haemorrhage is essential as vision may be preserved if intervention is prompt.9 Irreversible damage to retinal cells is thought to occur only after 100 min of ischaemia.10 It is therefore important that
other members of the team are aware of their role in the early recognition of this condition. With this is mind most surgeons would either record their requirements for eye observations in the operation note, or inform the nursing staff directly (presumably through the junior medical staff). Somewhat surprisingly only 44% of surgeons used a proforma for recording eye observations. In our unit we use the orbital observation chart first described by Hayter and Sugar.2 With the ever increasing reduction in hours worked by junior doctors, the recognition and initial management of retrobulbar haemorrage is all the more important, both for junior maxillofacial trainees and for other trainees who may see this condition (accident and emergency medical staff). Adequate explanation to patients who are discharged home of the possibility of this condition, and the likely symptoms, is equally important not only for vision, but also from a medicolegal perspective. As a result of this study, we have produced an advice sheet, which is given to patients who have been discharged, detailing the procedure to follow should their vision deteriorate (Appendix B).
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Appendix A. Questionnaire
413
414
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
Appendix B. Facial injury advice sheet
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
415
416
M.C. Bater et al. / British Journal of Oral and Maxillofacial Surgery 43 (2005) 410–416
References 1. Hislop WS, Dutton GN, Douglas PS. Treatment of retrobulbar haemorrhage in accident and emergency departments. Br J Oral Maxillofac Surg 1996;34:289–92. 2. Hayter JP, Sugar A. An orbital observation chart. Br J Oral Maxillofac Surg 1991;29:77–9. 3. Ord RA. Postoperative retrobulbar haemorrhage and blindness complicating trauma surgery. Br J Oral Surg 1981;19:202–7. 4. Morris TA, Ward-Booth RP. Delayed spontaneous retrobulbar haemorrhage—a case report. J Maxillofac Surg 1985;13:129–30. 5. Ghufoor K, Sandhu G, Sutcliffe J. Delayed onset of retrobulbar haemorrhage following severe head injury: a case report and review. Injury 1998;29:139–41.
6. Wood CM. The medical management of retrobulbar haemorrhage complicating facial fractures: a case report. Br J Oral Maxillofac Surg 1989;27:291–5. 7. Bailey WK, Kuo PC, Evans LS. Diagnosis and treatment of retrobulbar haemorrhage. J Oral Maxillofac Surg 1993;51:780–2. 8. Hislop WS, Dutton GN. Retrobulbar haemorrhage: can blindness be prevented? Injury 1994;25:663–5. 9. Heinze JB, Hueston JT. Blindness after blepharoplasty: mechanism and early reversal. Plast Reconstr Surg 1978;61:347–54. 10. Hayreh SS, Kolder HE, Weingeist TA. Central retinal occlusion and retinal tolerance time. Ophthalmology 1980;87:75–8.