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Management of acute retrobulbar haemorrhage: a survey of non-ophthalmic emergency department physicians
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  1. Matthew R Edmunds1,
  2. Anjana S Haridas1,
  3. Daniel S Morris1,
  4. Kasyap Jamalapuram2
  1. 1 Cardiff Eye Unit, University Hospital of Wales, Cardiff, UK
  2. 2 Emergency Department, Birmingham Children’s Hospital, Birmingham, UK
  1. Correspondence to Dr Matthew R Edmunds, Cardiff Eye Unit, University Hospital of Wales, Heath Park Way, Cardiff CF14 4XW, UK; matthew.r.edmunds{at}nhs.net

Abstract

Introduction Acute retrobulbar haemorrhage (RBH) with orbital compartment syndrome is a sight-threatening ophthalmic emergency requiring treatment with lateral canthotomy and cantholysis (LC/C). However, such cases may present to non-ophthalmic emergency departments (ED) out-of-hours, when specialist intervention is not readily available. We completed a survey of ED physicians to explore experiences of RBH and confidence in undertaking LC/C.

Methods From February to April 2018, an online survey was sent to ED physicians of all training grades in seven UK locations. The survey comprised a case vignette of a patient presenting with clinical features of RBH with orbital compartment syndrome, with multiple choice questions on the diagnosis, management and onward referral of such cases. Additional questions explored the experience of RBH, LC/C and perspectives on current and future training of ED physicians in this area.

Results 190 ED doctors completed the survey (response rate 70%). While 82.8% correctly diagnosed RBH and 95.7% recognised irreversible visual loss as a consequence of untreated RBH with orbital compartment syndrome, 78.7% indicated that they would initially undertake CT imaging rather than performing LC/C. Only 38.9% had previously encountered a case of RBH and only 37.1% would perform LC/C themselves, with 91.4% indicating that this was due to lack of training. 92.2% felt that more training was required for ED physicians in RBH management and performing LC/C.

Conclusion While cases of RBH with orbital compartment syndrome are infrequent, it is important that RBH management with the vital, sight-saving skill of LC/C is added to the United Kingdom Royal College of Emergency Medicine training curriculum. At present, though the majority of ED physicians can identify RBH, the minority are willing or able to undertake LC/C, potentially risking irreversible but avoidable visual loss.

  • retrobulbar haemorrhage
  • compartment syndrome
  • lateral canthotomy

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Key messages

What is already known on this subject

  • Acute retrobulbar haemorrhage with orbital compartment syndrome is a sight-threatening emergency that requires urgent treatment with lateral canthotomy and cantholysis.

  • Treatment of acute retrobulbar haemorrhage with orbital compartment syndrome should be a clinical decision, not postponed by orbital imaging, as delayed treatment risks irreversible visual loss.

What this study adds

  • UK emergency department physicians of all training grades are able to recognise symptoms and signs of acute retrobulbar haemorrhage and understand the consequences of delayed treatment.

  • At present, the majority of UK emergency department physicians do not feel confident or sufficiently skilled to undertake lateral canthotomy and cantholysis for acute retrobulbar haemorrhage, mainly due to lack of training and experience. 

Introduction

Acute retrobulbar haemorrhage (RBH) with orbital compartment syndrome is an uncommon but sight-threatening ophthalmic emergency that requires urgent treatment with lateral canthotomy and cantholysis (LC/C).1 2 Such cases may present to non-ophthalmic emergency departments (ED) out-of-hours and when specialist intervention is not readily available.

The most relevant cause of RBH from an ED point of view is trauma.3 However, other causes include cosmetic or reconstructive eyelid surgery, endoscopic sinus surgery and retrobulbar injections.4 RBH usually represents an arterial bleed, from rupture of the infraorbital artery or the anterior or posterior ethmoidal artery.1 Bleeding into the closed, non-expansile space of the orbit causes an increase in intraorbital pressure, an orbital compartment syndrome. This reduces perfusion of the optic nerve and retina, with subsequent ischaemia and permanent loss of vision.1 2 Emergency decompression of the orbit with LC/C is therefore urgently required.3

Consultant ED physicians have expertise in a wide array of invasive, interventional procedures. The Royal College of Emergency Medicine (RCEM) training curriculum includes such techniques as central venous cannulation, lumbar puncture, intercostal drains and abdominal paracentesis.5 The curriculum also states that ‘an Emergency Physician who has completed his or her training and is working in an ED without the inpatient services to provide the skills for rare, life-threatening conditions (eg, resuscitative thoracotomy, perimortem caesarean section) should acquire and ensure maintenance of skills via simulation courses, local training, etc’.6 However, training in LC/C is not currently found in the RCEM curriculum.

We aimed to evaluate if ED physicians in non-ophthalmic emergency departments: (1) recognise symptoms and signs of RBH with orbital compartment syndrome, (2) understand how to appropriately manage RBH, (3) feel confident in performing LC/C, and (4) feel more training in RBH management is necessary. The motivation for this study was to more fully understand the challenges experienced by ED physicians in such scenarios and to work toward strategies to overcome these challenges in the future.

Methods

From February to April 2018, an online questionnaire (SurveyMonkey; online supplementary appendix 1) was sent on a single occasion to ED physicians of all training grades in seven UK locations—Birmingham, Bristol, Cardiff, Dundee, Glasgow, London and Plymouth.

Supplemental material

The survey comprised a case vignette of a patient presenting to an ED with the typical presenting features of RBH with orbital compartment syndrome symptoms (pain, diplopia) and signs (proptosis, conjunctival chemosis, subconjunctival haemorrhage, tense globe to palpation, reduced visual acuity, sluggish pupil response, relative afferent pupillary defect and ophthalmoplegia). A photograph of the case was included. Respondents were asked a number of multiple-choice questions (MCQ) to determine if they could determine the correct diagnosis. The questionnaire then explored subsequent investigations and management decisions, as well as perspectives on reasons for reluctance to perform LC/C and opinions on current and future training in LC/C. This was followed by an educational segment on the importance of RBH and indications for LC/C, including an online video demonstrating the technique of emergency LC/C.

Results

There were 190 responses to the survey, with a response rate of 70%. The mean time of questionnaire completion was 4 min and 19 s. Of the participants, 46.3% were Consultant ED physicians while the remainders were ST1-8 specialist trainees or staff and associate specialist ED physicians (table 1).

Table 1

Number and percentage of questionnaire respondents by ED training grade

A summary of responses to each of the questions is provided in table 2. Of the respondents, 82.8% correctly identified RBH with orbital compartment syndrome as the diagnosis from the case vignette, with 10.1% believing that the case represented an injury resulting in a ruptured globe and 5.3% answering that the diagnosis was an orbital floor fracture.

Table 2

Multiple-choice questions asked of ED physicians in the questionnaire

While 95.7% knew that the consequence of delaying emergency LC/C is an irreversible visual loss, 78.7% responded that they would perform CT head and orbits prior to performing LC/C. In response to a separate question, only 52.7% would perform LC/C themselves as the initial step in management.

The most common reasons for not performing LC/C were lack of training (91.4%), not previously having seen LC/C being performed (75.2%), and concerns regarding damaging the patient’s eye (49.5%). Only 37.1% answered that they would be happy to perform LC/C themselves, rather than referring patients to another specialty, and 92.2% responded that they felt ED physicians required more training in performing LC/C.

Discussion

RBH with orbital compartment syndrome is rare.1 At present, the incidence of RBH after blunt facial trauma is cited to be lower than 1%.7 However, several studies suggest that delayed treatment of such cases is likely to result in permanent vision loss.1–3 In a study by Fattahi et al (2014), of 1386 patients with facial trauma, 50 (3.6%) had RBH. Of these, 85% of the 27 patients who underwent LC/C had full, or at least partial, recovery of vision.7

It is, therefore, concerning that 78.7% of ED physicians in the survey would perform CT orbits in cases of RBH with clinical features of compartment syndrome. Facial and orbital imaging may delay sight-saving treatment, resulting in permanent visual loss and should not take place until after surgical intervention, in the form of LC/C. Indeed, 60–100 min of raised orbital pressure may result in permanent visual loss.8 Intervention should be a purely clinical decision, unaffected by imaging.1 2

The earlier LC/C is performed the greater the likelihood of a return to previous visual acuity. Ideally, this should be within 120 min of injury.3 Initially, only inferior cantholysis may be performed, but superior cantholysis may also be required. Once LC/C (inferior and superior) has been performed, an ophthalmologist should be called urgently to assess the patient, as further interventions may be necessary. In due course, the outer canthal wound can either be left to heal itself or otherwise repaired by an ophthalmologist.

LC/C is among a number of interventions that ED physicians may need to undertake rarely. It has previously been acknowledged that for some time-critical, limb-saving or life-saving interventions such as tracheal intubation, intercostal drainage and resuscitative thoracotomy, ED physicians face considerable challenges in acquiring and maintaining skills.9 However, of these skills, it is only LC/C which is not currently present in the RCEM training curriculum.

There are some limitations to this study. The assessment was an online questionnaire and used a clinical vignette and image of a patient with very obvious symptoms, signs and clinical features of RBH with orbital compartment syndrome. ‘Real-life’ cases of RBH, with or without orbital compartment syndrome, may be considerably more subtle or complicated by, for example, the patient being intoxicated, or by an associated head injury, making clinical assessment more challenging.

The questionnaire may also not have permitted ED physicians to respond in a realistic manner. While participants were asked in a stepwise fashion what they would do in particular abstract situations, they would more than likely arrange for more than one thing to happen in a given instance. For example, requesting blood tests and orbital imaging, referring to ophthalmology and organising emergency LC/C all at the same time.

Lastly, the questionnaire did not allow differences in organisational structure between different units to be reflected. For example, while some ED physicians may have difficulty in accessing out-of-hours specialist ophthalmic services, some respondents commented that an ophthalmologist was always accessible and nearby, even out-of-hours.

Conclusion

To our knowledge, this is the first survey of the experience and perception of United Kingdom ED physicians in the context of RBH and LC/C. While the majority of ED physicians can identify RBH and understand the consequences of delayed treatment, only a minority feel confident or sufficiently skilled to undertake LC/C. Introducing this vital, sight-saving skill is an important change needed in the RCEM curriculum. It is crucial, however, that the specialties of Ophthalmology and Emergency Medicine work together to ensure high-quality training and regular maintenance of this skill.

Acknowledgments

The authors would like to thank the ED physicians in each of the different United Kingdom units who took the time to complete the questionnaire and provide their feedback. They would also like to thank Miss Amy Shirodkar (ST7 in Ophthalmology) for providing advice and feedback on the SurveyMonkey questionnaire.

References

Footnotes

  • Contributors MRE: conception and design, acquisition, analysis and interpretation of data for the work, drafting the work and revising it critically for important intellectual content; and final approval of the version to be published. ASH and DSM: analysis and interpretation of data for the work, drafting the work and revising it critically for important intellectual content; and final approval of the version to be published. KJ: design, analysis and interpretation of data for the work, drafting the work and revising it critically for important intellectual content; and final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Patient consent for publication Not required.

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