Periocular hematoma secondary to subperiosteal injury by a short needle
A 55-year-old obese woman (body mass index 35 kg/m2) with cataract in her left eye, was scheduled to undergo phacoemulsification with posterior chamber intraocular lens implantation, under local anesthesia. The preoperative assessment revealed long-standing history of diabetes, hypertension and hyperlipidemia that was poorly controlled. She also had residual right-sided hemiparesis for the last 4 years after an episode of cerebrovascular accident. She was also on medical therapy for degenerative joint disease.\nHer medications included amlodipine 10 mg/day, metformin 500 mg/day, simvastatin 20 mg, diclofenac 50 mg/day and aspirin 81 mg/day. Preoperative B- scan of the operating eye showed a normal axial length (21.23 mm) without staphayloma.\nPeribulbar block was performed by a senior anaesthesiologist using 25-G needle with a length of 16 mm (BD Microlane Drogheda, Ireland) by an inferotemporal approach. Ten milliters mixture of local anesthetics (lidocaine 2% and bupivicaine 0.5% in a 2:3 volume ratio respectively) together with hyaluronidase 5 IU/ml was used for the block. The patient was cooperative and did not feel any major discomfort in her eye during injection. A Honan-cuff balloon was applied after the block as a pressure reducing device for 10 minutes.\nThe patient began complaining of intense pain in the eye after 5 minutes. The Honan cuff balloon was removed immediately. The globe was proptotic with severe tension in the upper and lower eyelids. It was difficult to open the palpebral fissure. A subconjunctival hematoma was noted after forceful opening of the eyelids. A provisional diagnosis of intraorbital hematoma was made. The surgeon was consulted immediately and he performed an emergency lateral canthotomy. The conjunctiva was incised laterally and the hematoma was drained with the help of a canula. Twenty-five percent mannitol in a dose of 50 ml was given intravenously during the procedure and the cataract surgery was postponed.\nIntraocular pressure was measured 2 hours later and was found to be 35 mmHg (16 mmHg, base line examination). Patient was prescribed oral acetazolamide 250 mg four times a day. Ultrasound B-scan of left orbit after 6 hours showed posterior pole within normal limits with no evidence of intra-conal/orbital hemorrhage or signs of optic nerve avulsion. Computed tomography of the orbit showed a left periorbital soft tissue swelling with abnormal extraconal density in close proximity to the left lateral rectus muscle. The initial density was approximately 18-40 Hounsfield units with a length of approximately 2.9 cm and width of 0.6 cm. These features suggested an organized subperiostal hematoma in the left extraconal space.\nThe patient was discharged on the 3rd day of the incident and was seen again after 6 weeks for follow up. The periorbital swelling and bruising subsided significantly. The visual acuity was similar to the presenting acuity prior to the incident.