- Email: [email protected]
Retrobulbar hemorrhage following tooth extraction: Case report & anatomical correlation
Journal Pre-proof Retrobulbar hemorrhage following tooth extraction: Case report & anatomical correlation
Omar Suhaym, Osama Alghamdi, Julia Pompura PII:
S2214-5419(20)30003-1
DOI:
https://doi.org/10.1016/j.omsc.2020.100142
Reference:
OMSC 100142
To appear in:
Oral and Maxillofacial Surgery Cases
Received Date:
02 February 2020
Accepted Date:
13 February 2020
Please cite this article as: Omar Suhaym, Osama Alghamdi, Julia Pompura, Retrobulbar hemorrhage following tooth extraction: Case report & anatomical correlation, Oral and Maxillofacial Surgery Cases (2020), https://doi.org/10.1016/j.omsc.2020.100142
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Journal Pre-proof
Title: Retrobulbar hemorrhage following tooth extraction: Case report & anatomical correlation Authors: Omar Suhaym, DDS, FRCD(c),1,2 Osama Alghamdi DDS, FRCD(c)3, Julia Pompura, DDS, FRCD(c)4 1 Former
resident, Department of Oral and Maxillofacial Surgery, McGill University, Montreal,
QC, Canada 2 Teaching
assistant, Department of Maxillofacial Surgery and Diagnostic Sciences, King Saud bin
Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia 3 Assistant
professor, Department of Oral and Maxillofacial Surgery, King Saud University, Riyadh,
Saudi Arabia 4Associate
professor, Department of Oral and Maxillofacial Surgery, McGill University, Montreal,
QC, Canada Address correspondence to: Omar Suhaym, DDS, FRCD(c) (past address where the actual work was done) McGill University Health System Montreal General Hospital B3 131, 1650 ave Cedar Montreal, Quebec H3G 1A4
Email: [email protected] (current address) University of Illinois at Chicago College of Dentistry 801 S. Paulina St., Room 110 Chicago, IL 60612-7211 Email: [email protected] Phone: 312-996-1052 Fax: 312-996-5987 Mobile: 312-972-7730
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Co-authors affiliation addresses: Osama Alghamdi DDS, FRCD(c) King Saud University Maxillofacial Surgery Department, College of Dentistry Riyadh, Kingdom of Saudi Arabia Email: [email protected]
Julia Pompura, DDS, FRCD(c) McGill University Health System Montreal General Hospital B3 131, 1650 ave Cedar Montreal, Quebec H3G 1A4 Email: [email protected]
Keywords: retrobulbar hemorrhage, dental extraction complications, wisdom teeth, orbital hematoma, teeth extraction. Declarations of interest: none Abstract Word Count: 76 words Manuscript Word Count: 1110 words References: 16 References Figures: 5
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Abstract: Retrobulbar hemorrhage (RBH) is a rare but potentially devastating complication that can lead to permanent vision loss. Prompt identification and appropriate intervention are critical to avoid irreversible blindness. Practitioners are aware of the potential development of RBH secondary to orbital floor reconstruction, blepharoplasty, and endoscopic sinus surgery, however, rarely due to dental procedures. In this case report, we present RBH resulting following upper wisdom tooth extraction and to review the possible anatomical pathway underlying this complication. Introduction: Retrobulbar hemorrhage (RBH) is an infrequent orbital complication with potential sightthreatening sequela. Vision loss can result either from direct hypoperfusion to the optic nerve or compression and stasis of the central retinal vasculature that could lead to permanent neuropathy.(1) The etiology of orbital hematoma classified as traumatic, iatrogenic , or spontaneous. Iatrogenically, several procedures can cause RBH such as endoscopic sinus surgery, blepharoplasty, retrobulbar injections, or reconstructive trauma surgery.(2–7) Early recognition, accurate diagnosis, and prompt management of retrobulbar hemorrhage are essential to prevent irreversible blindness. The aim of this case report is to describe a unique case of RBH following upper wisdom tooth extraction and demonstrate the probable anatomical correlation.
Journal Pre-proof
Case report: A 27-year-old healthy woman presented to the Oral and Maxillofacial Surgery outpatient clinic at the Montreal General Hospital two hours after having her upper left wisdom tooth extracted by a general dentist. She complained of pain, intermittent blurriness, and double vision following the extraction. Clinical examination revealed a firm swelling of the patient’s left cheek, left periorbital ecchymosis, left subconjunctival hemorrhage, and significant proptosis of the left orbit. Her pupils were equal and reactive to light and accommodation. The remainder of the face and neck physical exam was unremarkable. An ophthalmology team performed a comprehensive orbital exam, which confirmed a mild decrease in visual acuity in the left eye (VA20/25) with diplopia, mildly elevated intraocular pressure (23 mmHg), and exophthalmometry measuring 29 mm of the left orbit (OD 20 mm). Based on the clinical presentation, an urgent computed tomography (CT) scan was obtained. The CT scan showed significant subcutaneous emphysema involving the left masticator space, which extended to the left eye through the inferior orbital fissure. The scan also revealed a 1.3 x 1.3 cm extraconal hematoma causing minimal mass effect on the inferior and lateral rectus muscles. The patient was taken urgently to the operating room for lateral canthotomy and cantholysis and evacuation of the hematoma. Following the procedure, the patient reported immediate relief of pressure and pain. The postop clinical examination performed the day after surgery revealed the resolution of visual blurring and binocular diplopia. The patient stayed in
Journal Pre-proof
the hospital for two days for monitoring and has since undergone an uneventful post-operative course. Discussion: The orbital cavity is an enclosed space that bonded by four rigid bony walls and relatively inflexible anterior orbital septum and eyelids. Hence, it has a limited ability to expand when a rapid increase in volume occurs, followed by an acute rise in orbital pressure. Similar to other compartment syndromes, pressure-volume dynamics will cause tissue hypoperfusion and eventually, vision loss. (8) Additionally, the orbit has no lymphatic drainage; major veins such as the superior ophthalmic vein are the only pathway outflow, so when compromised, it will further worsen the situation.(9) The progressive visual impairment can be tributary to central retinal artery occlusion, direct compressive optic neuropathy or vasculature, and ischemic optic neuropathy as the result of stretching of the nourishing blood-vessels. Patients can develop with a wide range of clinical features, including pain, proptosis, chemosis, diplopia, subconjunctival haemorrhage, elevated intraocular pressure, tense globe, loss of direct pupillary light reflex, ophthalmoplegia, and progressive loss of visual acuity.(5) According to a recent systematic review of factors related to outcomes(10), the presence of blindness or ophthalmoplegia are predictive of irreversible vision loss. Moreover, an additive number of clinical features indicates a progressive pathological process and associated with permanent blindness. Based on an experimental model of RBH, if decompression is not carried out within 60-100 minutes, it is likely to develop irreversible damage.(11,12) This correlates well with the time-sensitivity outcome presented by Christie et al.(10), which demonstrates a shorter
Journal Pre-proof
time to treatment is associated with a stronger likelihood of complete recovery. To our knowledge, only three cases of RBH following a tooth extraction have been described in the literature. In 2006 Warburton and Brahim(13) reported RBH developed 48 hours after uncomplicated upper third molars. Close observation and medical management resulted in complete resolution and no residual functional deficit. Goshtasby et al.(14) reported RBH that developed in the recovery room after an uneventful extraction of all wisdom teeth under conscious sedation. The patient underwent evacuation of cheek hematoma and ligation of the bleeding vessel. The CT scan showed a small RBH, and the ophthalmological exam was normal except for subconjunctival hemorrhage. Thus, conservative management was sufficient, and the patient had no adverse visual sequala. The third case was described by Baba et al. after upper wisdom teeth extraction complicated by maxillary tuberosity fracture and small RBH.(15) The patient developed small RBH at the inferior orbital fissure area and slight diplopia at the lateral gaze. Likewise, the case was managed conservatively and without further unfavorable complications. In our case, only a mild increase in intraocular pressure was noted. However, given the patient’s clinical presentation of pressure pain, blurriness, decrease visual acuity, and diplopia, we preferred a surgical decompression approach plus close monitoring post-operatively. Our approach to the manage this intra-orbital hematoma resulted in complete resolution of the symptoms, without any complications or functional impairment to the patient. The question remain what is the etiology of retrobulbar hematoma following the removal of an upper left third molar? two possible explanations were proposed in the literature; both
Journal Pre-proof
theories give consideration to the anatomy of the infratemporal and pterygopalatine fossae and its communications. Anatomically, the infratemporal fossa has direct communication via the anterior part of the inferior orbital fissure. In a deeper location, the posterior part of the inferior orbital fissure still communicates with the pterygopalatine fossa.(16) Thus, a route by which blood can accumulate as an extraconal RBH. One pathway implies that bleeding from branches of the posterior superior alveolar artery during or after the extraction could retract superiorly through the pterygomaxillary fissure into the pterygopalatine fossa and, ultimately, into the retro-orbital space via the inferior orbital fissure. The other possibility is that hemorrhaging could occur from pterygoid plexus or other fragile tributary vessels of the plexus. A bleed from the plexus or its tributary vessels can course through the pterygomaxillary and infratemporal spaces into the intra-orbital compartment via the inferior orbital fissure. Alternatively, Valsalva maneuver and fracture in the maxillary bone can be potential causes, but both have been ruled out in our case based on history and CT scan findings. In conclusion, we report a unique case of retrobulbar hemorrhage developed following a wisdom tooth extraction. Wisdom teeth extraction is a procedure done thousands of times on a daily basis, and it is crucial to be aware of the potential complications even though the incidence of RBH post-extraction is extremely rare. Essentially, RBH requires immediate recognition and prompt intervention to prevent irreversible loss of vision.
Journal Pre-proof
References: 1. Bailey WK, Kuo PC, Evans LS. Diagnosis and treatment of retrobulbar hemorrhage. Journal of Oral and Maxillofacial Surgery. 1993 Jul 1;51(7):780–2. 2. Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of 727 cases. Otolaryngol Head Neck Surg. 1983 Jun;91(3):276–9. 3. Wood GD. Blindness following fracture of the zygomatic bone. Br J Oral Maxillofac Surg. 1986 Feb;24(1):12–6. 4. Ruben S. The incidence of complications associated with retrobulbar injection of anaesthetic for ophthalmic surgery. Acta Ophthalmol (Copenh). 1992 Dec;70(6):836–8. 5. Rosdeutscher JD, Stadelmann WK. Diagnosis and treatment of retrobulbar hematoma resulting from blunt periorbital trauma. Ann Plast Surg. 1998 Dec;41(6):618–22. 6. Saussez S, Choufani G, Brutus JP, Cordonnier M, Hassid S. Lateral canthotomy: a simple and safe procedure for orbital haemorrhage secondary to endoscopic sinus surgery. Rhinology. 1998 Mar;36(1):37–9. 7. Wolfort FG, Vaughan TE, Wolfort SF, Nevarre DR. Retrobulbar hematoma and blepharoplasty. Plast Reconstr Surg. 1999 Dec;104(7):2154–62. 8. Dolman PJ, Glazer LC, Harris GJ, Beatty RL, Massaro BM. Mechanisms of visual loss in severe proptosis. Ophthalmic Plast Reconstr Surg. 1991;7(4):256–60.
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9. Dalley RW, Robertson WD, Rootman J. Globe tenting: a sign of increased orbital tension. AJNR Am J Neuroradiol. 1989 Feb;10(1):181–6. 10. Christie B, Block L, Ma Y, Wick A, Afifi A. Retrobulbar hematoma: A systematic review of factors related to outcomes. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2018 Feb;71(2):155–61. 11. Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. 1980 Jan;87(1):75–8. 12. Young VL, Talley AR, Pin P, Trick GL, Becker W, Logan SE, et al. The relationship of retrobulbar hematomas to vision in cynomolgus monkeys. Plast Reconstr Surg. 1990 May;85(5):698–703; discussion 704-705. 13. Warburton G, Brahim JS. Intraorbital Hematoma After Removal of Upper Third Molar: A Case Report. Journal of Oral and Maxillofacial Surgery. 2006 Apr;64(4):700–4. 14. Goshtasby P, Miremadi R, Warwar R. Retrobulbar Hematoma After Third Molar Extraction: Case Report and Review. Journal of Oral and Maxillofacial Surgery. 2010 Feb;68(2):461–4. 15. Baba J, Iwai T, Endo H, Aoki N, Tohnai I. Maxillary tuberosity fracture and ophthalmologic complications following removal of maxillary third molar. Oral Surg. 2017 Feb;10(1):43–7. 16. René C. Update on orbital anatomy. Eye. 2006 Oct;20(10):1119–29.
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Figure legends:
Figure 1: Clinical appearance of the patient following the upper left wisdom tooth extraction showing left facial swelling, decreased visual acuity, exophthalmos, and sub-conjunctival hemorrhage of the left orbit. Figure 2: Panoramic radiograph following the upper wisdom teeth extraction. Figure 3: Axial and sagittal cuts of the computed tomography scan, showing a 1.3 x 1.3 cm extraconal hematoma of the left orbit.
Figure 1
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Figure 2
Figure 3
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Retrobulbar hemorrhage is a rare entity that could develop from orbital floor reconstruction, blepharoplasty, endoscopic sinus surgery, and dental extraction. Awareness about rare complications is essential knowledge for common procedures such as dental extraction. Early identification and appropriate intervention are critical to avoid irreversible blindness.
Omar Suhaym, Osama Alghamdi, Julia Pompura PII:
S2214-5419(20)30003-1
DOI:
https://doi.org/10.1016/j.omsc.2020.100142
Reference:
OMSC 100142
To appear in:
Oral and Maxillofacial Surgery Cases
Received Date:
02 February 2020
Accepted Date:
13 February 2020
Please cite this article as: Omar Suhaym, Osama Alghamdi, Julia Pompura, Retrobulbar hemorrhage following tooth extraction: Case report & anatomical correlation, Oral and Maxillofacial Surgery Cases (2020), https://doi.org/10.1016/j.omsc.2020.100142
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Journal Pre-proof
Title: Retrobulbar hemorrhage following tooth extraction: Case report & anatomical correlation Authors: Omar Suhaym, DDS, FRCD(c),1,2 Osama Alghamdi DDS, FRCD(c)3, Julia Pompura, DDS, FRCD(c)4 1 Former
resident, Department of Oral and Maxillofacial Surgery, McGill University, Montreal,
QC, Canada 2 Teaching
assistant, Department of Maxillofacial Surgery and Diagnostic Sciences, King Saud bin
Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia 3 Assistant
professor, Department of Oral and Maxillofacial Surgery, King Saud University, Riyadh,
Saudi Arabia 4Associate
professor, Department of Oral and Maxillofacial Surgery, McGill University, Montreal,
QC, Canada Address correspondence to: Omar Suhaym, DDS, FRCD(c) (past address where the actual work was done) McGill University Health System Montreal General Hospital B3 131, 1650 ave Cedar Montreal, Quebec H3G 1A4
Email: [email protected] (current address) University of Illinois at Chicago College of Dentistry 801 S. Paulina St., Room 110 Chicago, IL 60612-7211 Email: [email protected] Phone: 312-996-1052 Fax: 312-996-5987 Mobile: 312-972-7730
Journal Pre-proof
Co-authors affiliation addresses: Osama Alghamdi DDS, FRCD(c) King Saud University Maxillofacial Surgery Department, College of Dentistry Riyadh, Kingdom of Saudi Arabia Email: [email protected]
Julia Pompura, DDS, FRCD(c) McGill University Health System Montreal General Hospital B3 131, 1650 ave Cedar Montreal, Quebec H3G 1A4 Email: [email protected]
Keywords: retrobulbar hemorrhage, dental extraction complications, wisdom teeth, orbital hematoma, teeth extraction. Declarations of interest: none Abstract Word Count: 76 words Manuscript Word Count: 1110 words References: 16 References Figures: 5
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Abstract: Retrobulbar hemorrhage (RBH) is a rare but potentially devastating complication that can lead to permanent vision loss. Prompt identification and appropriate intervention are critical to avoid irreversible blindness. Practitioners are aware of the potential development of RBH secondary to orbital floor reconstruction, blepharoplasty, and endoscopic sinus surgery, however, rarely due to dental procedures. In this case report, we present RBH resulting following upper wisdom tooth extraction and to review the possible anatomical pathway underlying this complication. Introduction: Retrobulbar hemorrhage (RBH) is an infrequent orbital complication with potential sightthreatening sequela. Vision loss can result either from direct hypoperfusion to the optic nerve or compression and stasis of the central retinal vasculature that could lead to permanent neuropathy.(1) The etiology of orbital hematoma classified as traumatic, iatrogenic , or spontaneous. Iatrogenically, several procedures can cause RBH such as endoscopic sinus surgery, blepharoplasty, retrobulbar injections, or reconstructive trauma surgery.(2–7) Early recognition, accurate diagnosis, and prompt management of retrobulbar hemorrhage are essential to prevent irreversible blindness. The aim of this case report is to describe a unique case of RBH following upper wisdom tooth extraction and demonstrate the probable anatomical correlation.
Journal Pre-proof
Case report: A 27-year-old healthy woman presented to the Oral and Maxillofacial Surgery outpatient clinic at the Montreal General Hospital two hours after having her upper left wisdom tooth extracted by a general dentist. She complained of pain, intermittent blurriness, and double vision following the extraction. Clinical examination revealed a firm swelling of the patient’s left cheek, left periorbital ecchymosis, left subconjunctival hemorrhage, and significant proptosis of the left orbit. Her pupils were equal and reactive to light and accommodation. The remainder of the face and neck physical exam was unremarkable. An ophthalmology team performed a comprehensive orbital exam, which confirmed a mild decrease in visual acuity in the left eye (VA20/25) with diplopia, mildly elevated intraocular pressure (23 mmHg), and exophthalmometry measuring 29 mm of the left orbit (OD 20 mm). Based on the clinical presentation, an urgent computed tomography (CT) scan was obtained. The CT scan showed significant subcutaneous emphysema involving the left masticator space, which extended to the left eye through the inferior orbital fissure. The scan also revealed a 1.3 x 1.3 cm extraconal hematoma causing minimal mass effect on the inferior and lateral rectus muscles. The patient was taken urgently to the operating room for lateral canthotomy and cantholysis and evacuation of the hematoma. Following the procedure, the patient reported immediate relief of pressure and pain. The postop clinical examination performed the day after surgery revealed the resolution of visual blurring and binocular diplopia. The patient stayed in
Journal Pre-proof
the hospital for two days for monitoring and has since undergone an uneventful post-operative course. Discussion: The orbital cavity is an enclosed space that bonded by four rigid bony walls and relatively inflexible anterior orbital septum and eyelids. Hence, it has a limited ability to expand when a rapid increase in volume occurs, followed by an acute rise in orbital pressure. Similar to other compartment syndromes, pressure-volume dynamics will cause tissue hypoperfusion and eventually, vision loss. (8) Additionally, the orbit has no lymphatic drainage; major veins such as the superior ophthalmic vein are the only pathway outflow, so when compromised, it will further worsen the situation.(9) The progressive visual impairment can be tributary to central retinal artery occlusion, direct compressive optic neuropathy or vasculature, and ischemic optic neuropathy as the result of stretching of the nourishing blood-vessels. Patients can develop with a wide range of clinical features, including pain, proptosis, chemosis, diplopia, subconjunctival haemorrhage, elevated intraocular pressure, tense globe, loss of direct pupillary light reflex, ophthalmoplegia, and progressive loss of visual acuity.(5) According to a recent systematic review of factors related to outcomes(10), the presence of blindness or ophthalmoplegia are predictive of irreversible vision loss. Moreover, an additive number of clinical features indicates a progressive pathological process and associated with permanent blindness. Based on an experimental model of RBH, if decompression is not carried out within 60-100 minutes, it is likely to develop irreversible damage.(11,12) This correlates well with the time-sensitivity outcome presented by Christie et al.(10), which demonstrates a shorter
Journal Pre-proof
time to treatment is associated with a stronger likelihood of complete recovery. To our knowledge, only three cases of RBH following a tooth extraction have been described in the literature. In 2006 Warburton and Brahim(13) reported RBH developed 48 hours after uncomplicated upper third molars. Close observation and medical management resulted in complete resolution and no residual functional deficit. Goshtasby et al.(14) reported RBH that developed in the recovery room after an uneventful extraction of all wisdom teeth under conscious sedation. The patient underwent evacuation of cheek hematoma and ligation of the bleeding vessel. The CT scan showed a small RBH, and the ophthalmological exam was normal except for subconjunctival hemorrhage. Thus, conservative management was sufficient, and the patient had no adverse visual sequala. The third case was described by Baba et al. after upper wisdom teeth extraction complicated by maxillary tuberosity fracture and small RBH.(15) The patient developed small RBH at the inferior orbital fissure area and slight diplopia at the lateral gaze. Likewise, the case was managed conservatively and without further unfavorable complications. In our case, only a mild increase in intraocular pressure was noted. However, given the patient’s clinical presentation of pressure pain, blurriness, decrease visual acuity, and diplopia, we preferred a surgical decompression approach plus close monitoring post-operatively. Our approach to the manage this intra-orbital hematoma resulted in complete resolution of the symptoms, without any complications or functional impairment to the patient. The question remain what is the etiology of retrobulbar hematoma following the removal of an upper left third molar? two possible explanations were proposed in the literature; both
Journal Pre-proof
theories give consideration to the anatomy of the infratemporal and pterygopalatine fossae and its communications. Anatomically, the infratemporal fossa has direct communication via the anterior part of the inferior orbital fissure. In a deeper location, the posterior part of the inferior orbital fissure still communicates with the pterygopalatine fossa.(16) Thus, a route by which blood can accumulate as an extraconal RBH. One pathway implies that bleeding from branches of the posterior superior alveolar artery during or after the extraction could retract superiorly through the pterygomaxillary fissure into the pterygopalatine fossa and, ultimately, into the retro-orbital space via the inferior orbital fissure. The other possibility is that hemorrhaging could occur from pterygoid plexus or other fragile tributary vessels of the plexus. A bleed from the plexus or its tributary vessels can course through the pterygomaxillary and infratemporal spaces into the intra-orbital compartment via the inferior orbital fissure. Alternatively, Valsalva maneuver and fracture in the maxillary bone can be potential causes, but both have been ruled out in our case based on history and CT scan findings. In conclusion, we report a unique case of retrobulbar hemorrhage developed following a wisdom tooth extraction. Wisdom teeth extraction is a procedure done thousands of times on a daily basis, and it is crucial to be aware of the potential complications even though the incidence of RBH post-extraction is extremely rare. Essentially, RBH requires immediate recognition and prompt intervention to prevent irreversible loss of vision.
Journal Pre-proof
References: 1. Bailey WK, Kuo PC, Evans LS. Diagnosis and treatment of retrobulbar hemorrhage. Journal of Oral and Maxillofacial Surgery. 1993 Jul 1;51(7):780–2. 2. Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of 727 cases. Otolaryngol Head Neck Surg. 1983 Jun;91(3):276–9. 3. Wood GD. Blindness following fracture of the zygomatic bone. Br J Oral Maxillofac Surg. 1986 Feb;24(1):12–6. 4. Ruben S. The incidence of complications associated with retrobulbar injection of anaesthetic for ophthalmic surgery. Acta Ophthalmol (Copenh). 1992 Dec;70(6):836–8. 5. Rosdeutscher JD, Stadelmann WK. Diagnosis and treatment of retrobulbar hematoma resulting from blunt periorbital trauma. Ann Plast Surg. 1998 Dec;41(6):618–22. 6. Saussez S, Choufani G, Brutus JP, Cordonnier M, Hassid S. Lateral canthotomy: a simple and safe procedure for orbital haemorrhage secondary to endoscopic sinus surgery. Rhinology. 1998 Mar;36(1):37–9. 7. Wolfort FG, Vaughan TE, Wolfort SF, Nevarre DR. Retrobulbar hematoma and blepharoplasty. Plast Reconstr Surg. 1999 Dec;104(7):2154–62. 8. Dolman PJ, Glazer LC, Harris GJ, Beatty RL, Massaro BM. Mechanisms of visual loss in severe proptosis. Ophthalmic Plast Reconstr Surg. 1991;7(4):256–60.
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9. Dalley RW, Robertson WD, Rootman J. Globe tenting: a sign of increased orbital tension. AJNR Am J Neuroradiol. 1989 Feb;10(1):181–6. 10. Christie B, Block L, Ma Y, Wick A, Afifi A. Retrobulbar hematoma: A systematic review of factors related to outcomes. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2018 Feb;71(2):155–61. 11. Hayreh SS, Kolder HE, Weingeist TA. Central retinal artery occlusion and retinal tolerance time. Ophthalmology. 1980 Jan;87(1):75–8. 12. Young VL, Talley AR, Pin P, Trick GL, Becker W, Logan SE, et al. The relationship of retrobulbar hematomas to vision in cynomolgus monkeys. Plast Reconstr Surg. 1990 May;85(5):698–703; discussion 704-705. 13. Warburton G, Brahim JS. Intraorbital Hematoma After Removal of Upper Third Molar: A Case Report. Journal of Oral and Maxillofacial Surgery. 2006 Apr;64(4):700–4. 14. Goshtasby P, Miremadi R, Warwar R. Retrobulbar Hematoma After Third Molar Extraction: Case Report and Review. Journal of Oral and Maxillofacial Surgery. 2010 Feb;68(2):461–4. 15. Baba J, Iwai T, Endo H, Aoki N, Tohnai I. Maxillary tuberosity fracture and ophthalmologic complications following removal of maxillary third molar. Oral Surg. 2017 Feb;10(1):43–7. 16. René C. Update on orbital anatomy. Eye. 2006 Oct;20(10):1119–29.
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Figure legends:
Figure 1: Clinical appearance of the patient following the upper left wisdom tooth extraction showing left facial swelling, decreased visual acuity, exophthalmos, and sub-conjunctival hemorrhage of the left orbit. Figure 2: Panoramic radiograph following the upper wisdom teeth extraction. Figure 3: Axial and sagittal cuts of the computed tomography scan, showing a 1.3 x 1.3 cm extraconal hematoma of the left orbit.
Figure 1
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Figure 2
Figure 3
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Retrobulbar hemorrhage is a rare entity that could develop from orbital floor reconstruction, blepharoplasty, endoscopic sinus surgery, and dental extraction. Awareness about rare complications is essential knowledge for common procedures such as dental extraction. Early identification and appropriate intervention are critical to avoid irreversible blindness.