Journal of Pediatric Ophthalmology and Strabismus

Posttraumatic Subgaleal Hematoma Extending into the Orbit as a Cause of Permanent Blindness

J Reimer Wolter, MD; Gilbert J Vanderveen, MD; Richard L Wacksman, MD

Abstract

Subperiosteal hematomas of the head and of the orbits are most common in children and young people; however, they may rarely also occur in older persons.1"3 Blunt head trauma is the typical cause and these hematomas may be associated with skull fractures. Subperiosteal hematomas of the orbit are relatively common in newborn babies. These hematomas usually clear by slow resorption of the blood. However, infection of the hematomas as well as organization leading to a permanent orbital tumor may complicate the situation. Large subperiosteal hematomas of the orbit may exhibit all the problems of other space-taking orbital processes. Drainage of orbital hematomas by needle aspiration is usually indicated to prevent these secondary problems.4

Extension of a subgaleal hematoma resulting from blunt head tra urna into one orbit to cause a large subperiosteal orbital hematoma and permanent blindness of the involved eye in the unusual case of the present 16-year-old boy is reported in the present paper.

CASE REPORT

This 16-year-old white male fell off his bicycle on 8/24/77 and hit the ground with his left forehead. There was no evidence of immediate serious problems. One day later, however, some swelling and redness of the skin was observed in the area of the injury on the left forehead. Two days after the injury the patient developed more swelling in this area. He went to the emergency room of a local hospital. Roentgenograms were obtained and these were negative. No treatment of any kind was initiated. Three days after the injury, dizziness and blurred vision were experienced by the patient in addition to further increase of the swelling on the left forehead as well as additional swelling of the left eyelids. Progressive swelling and additional neck stiffness were observed four days after the accident.

On 8/29/77 the patient was admitted to a local hospital with complaints of nausea and vomiting in addition to progressively increasing swelling of his head and both preorbitai regions. A prominent subgaleal scalp hematoma was found. The patient had a temperature of 100.2 and a blood pressure of 150/90. Funduscopic examination is reported to have revealed "venous congestion, but no papilledema" in either eye. The tympanic membranes were clear and there was a negative Babinski bilaterally. Skull x-rays were repeated and found to be negative.

On 8/30/77 the boy was seen by a local neurosurgeon who diagnosed "a massive right cephalhematoma." The following day the patient was seen by an ophthalmologist who found marked proptosis and complete blindness of the right eye. The right pupil is reported to have been dilated and fixed. The discovery of a blind right eye led to an emergency transfer of the patient to this University Hospital in the evening of 8/31/77.

The initial evaluation at the University of Michigan Hospital revealed a visual acuity of blindness in the right eye and 20/20 in the left. A left visual field was normal. The 16-year-old boy was small for his age and had a congenitally crippled right thumb (Fig. 1) and a cafe-au-lait spot measuring about 1 0 mm in its greatest diameter in front of the right ear. He was alert and did not complain of any pain. However, his head was swollen due to a large subgaleal hematoma involving all of his scalp (Fig. 1 ). Both eyes exhibited extensive lid hematomas (Fig. 1). Distinct proptosis with exposure keratitis was present on the right side. Extraocular motility was markedly limited in the right eye, but it was normal in the left. Both pupils were fixed and dilated due to mydriatic eye drops used earlier that day by the referring physicians. Fundus examination…

Subperiosteal hematomas of the head and of the orbits are most common in children and young people; however, they may rarely also occur in older persons.1"3 Blunt head trauma is the typical cause and these hematomas may be associated with skull fractures. Subperiosteal hematomas of the orbit are relatively common in newborn babies. These hematomas usually clear by slow resorption of the blood. However, infection of the hematomas as well as organization leading to a permanent orbital tumor may complicate the situation. Large subperiosteal hematomas of the orbit may exhibit all the problems of other space-taking orbital processes. Drainage of orbital hematomas by needle aspiration is usually indicated to prevent these secondary problems.4

Extension of a subgaleal hematoma resulting from blunt head tra urna into one orbit to cause a large subperiosteal orbital hematoma and permanent blindness of the involved eye in the unusual case of the present 16-year-old boy is reported in the present paper.

CASE REPORT

This 16-year-old white male fell off his bicycle on 8/24/77 and hit the ground with his left forehead. There was no evidence of immediate serious problems. One day later, however, some swelling and redness of the skin was observed in the area of the injury on the left forehead. Two days after the injury the patient developed more swelling in this area. He went to the emergency room of a local hospital. Roentgenograms were obtained and these were negative. No treatment of any kind was initiated. Three days after the injury, dizziness and blurred vision were experienced by the patient in addition to further increase of the swelling on the left forehead as well as additional swelling of the left eyelids. Progressive swelling and additional neck stiffness were observed four days after the accident.

On 8/29/77 the patient was admitted to a local hospital with complaints of nausea and vomiting in addition to progressively increasing swelling of his head and both preorbitai regions. A prominent subgaleal scalp hematoma was found. The patient had a temperature of 100.2 and a blood pressure of 150/90. Funduscopic examination is reported to have revealed "venous congestion, but no papilledema" in either eye. The tympanic membranes were clear and there was a negative Babinski bilaterally. Skull x-rays were repeated and found to be negative.

On 8/30/77 the boy was seen by a local neurosurgeon who diagnosed "a massive right cephalhematoma." The following day the patient was seen by an ophthalmologist who found marked proptosis and complete blindness of the right eye. The right pupil is reported to have been dilated and fixed. The discovery of a blind right eye led to an emergency transfer of the patient to this University Hospital in the evening of 8/31/77.

The initial evaluation at the University of Michigan Hospital revealed a visual acuity of blindness in the right eye and 20/20 in the left. A left visual field was normal. The 16-year-old boy was small for his age and had a congenitally crippled right thumb (Fig. 1) and a cafe-au-lait spot measuring about 1 0 mm in its greatest diameter in front of the right ear. He was alert and did not complain of any pain. However, his head was swollen due to a large subgaleal hematoma involving all of his scalp (Fig. 1 ). Both eyes exhibited extensive lid hematomas (Fig. 1). Distinct proptosis with exposure keratitis was present on the right side. Extraocular motility was markedly limited in the right eye, but it was normal in the left. Both pupils were fixed and dilated due to mydriatic eye drops used earlier that day by the referring physicians. Fundus examination revealed normal findings in both eyes and the intraocular pressures were also normal.

Fig. 1. The present patient on 8/31 / 77 exhibiting the extensive subgaleal hematoma, bilateral periorbital hematomas and right proptosis. The crippled right thumb is also seen.

Fig. 1. The present patient on 8/31 / 77 exhibiting the extensive subgaleal hematoma, bilateral periorbital hematomas and right proptosis. The crippled right thumb is also seen.

Fig. 2. Computerized transaxial tomogram through the top of the skull of the present patient showing the large subgaleal hematoma.

Fig. 2. Computerized transaxial tomogram through the top of the skull of the present patient showing the large subgaleal hematoma.

Fig. 3. Computerized transaxial tomographic cut through the skull of the present patient slightly superior to the orbits showing the large subgaleal hematoma in the region of the forehead.

Fig. 3. Computerized transaxial tomographic cut through the skull of the present patient slightly superior to the orbits showing the large subgaleal hematoma in the region of the forehead.

Fig. 4. Tomographic cut through the level of the orbits of the present patient showing the right orbital hematoma and exophthalmus.

Fig. 4. Tomographic cut through the level of the orbits of the present patient showing the right orbital hematoma and exophthalmus.

About 300 cc of blood were removed from the left scalp by a neurosurgeon and about 4 cc of dark blood were aspirated from a suspected subperiosteal hematoma on the roof of the right orbit by one of the authors shortly thereafter. This resulted in immediate decrease of the right exophthalmus, butthere was no return of vision to the right eye.

The patient was aamitted. Laboratory studies revealed a white count of 18,900 and a prothrombin time of 14 seconds with 55 percent activity. Intravenous Keflin was started to prevent secondary infection of the hematomas. However, the patient remained febrile in spite of this with his temperature frequently elevated to 1 00.2 and slowly decreasing to 99 degrees. An afferent pupillary defect became obvious on the right side as soon as the action of the dilating drops had subsided.

A cerebral angiogram done on 9/3/77 did not show a site of active bleeding nor did it reveal a carotid cavernous sinus fistula. It did show a downward displacement of the right ophthalmic artery suggesting a subperiosteal hematoma on the orbital roof. Computerized tomography done on the sa me day showed the newly filled and large subgaleal hematoma (Figs. 2, 3, & 4} as well as the distinct right propotisis (Figs. 4 & 5). Shortly following these studies seven more cc of dark blood were aspirated from the right orbit. Again, an immediate decrease of the proptosis was observed. Cultures taken from the aspirated blood remained negative. The scalp hematoma was drained on two more occasions by the neurosurgeons, but it kept reforming in spite of the application of an elastic bandage. When placement of a valve (Hemovac) was considered, the rebleeding stoped, finally.

Fig. 5. Higher power view of the tomographic cut demonstrating the orbital hematoma and exophthatmus in the present case.

Fig. 5. Higher power view of the tomographic cut demonstrating the orbital hematoma and exophthatmus in the present case.

In 9/4/77 the white blood count had decreased to 10,500, but the hematocrit had dropped to 26.2 and the hemoglobin to 9.1. One unit of blood was given as a transfusion. On 9/5/77 papilledema was first observed in the blind right eye. The left eye remained normal.

After 9/6/77 the boy became afebrile and there was continuing improvement of the hematomas in the head region. The right eye moved freely, but it remained blind. The right papilledema became less prominent, but it was still present when the boy was discharged on 9/13/77 to go back to the care of his local physicians. By a telephone call to the referring ophthalmologist it was learned that optic atrophy appeared in the right eye about two weeks later and that this eye remained blind.

DISCUSSION

Blindness following orbital floor fractures has had recent attention in the ophthalmological literature.5'6 Blindness due to pressure on the optic nerve or interruption of its blood supply is also well known to occur after orbital surgery or trauma. To the best of our knowledge, blindnessfollowing a subperiosteal hematoma of the orbit has not been reported before. Delayed blindness may also rarely occur hours or days after orbial floor blowout fractures.5'6 Delayed blindness in a case of delayed subgaleal hematoma that extended into one orbit to cause a subperiosteal hematoma must be a very unusual occurrence. It is of special interest that all these problems were the result of a rather slight injury. In spite of the presence of one congenially deformed thumb and one cafe-au-lait spot the present patient had no serious underlying disease. However, the fever is thought to indicate a low-grade infection of the hematomas that was controlled with antibiotics.

In the present case, the subperiosteal hematoma of the right orbit is not believed to be directly related to a blunt head injury to the left forehead. Every orbital surgeon knows that the orbital periosteum is not very firmly attached tp the orbital bones and that separation is especially easy in children. It is, thus, assumed that the enormous subgaleal hematoma in the present case secondarily separated the periosteum in the region of the right orbital rim and extended under the periosteum of the right orbital roof. The resulting orbital hematoma, in turn, caused the permanentdamage to the right optic nerve. It is important to recognize the possibility of this dangerous complication in the clinical care of subgaleal hematomas.

The loss of vision in the right eye is explained by compression of the right optic nerve or its blood supply by the subperiosteal hematoma extending from the orbital roof. Early aspiration of this hematoma probably could have prevented the resulting blindness, but due to a remarkable lack of severe symptoms the damage was probably already permanent when the loss of vision in the right eye was first discovered.

SUMMARY

A delayed subgaleal hematoma developing after blunt head trauma extended into the right orbit to form a subperiosteal hematoma on the orbital roof. Permanent blindness was found in the involved eye six days after the injury.

REFERENCES

1. Mueller W, Geppert J; Traumatisches subperiostales haematom der orbita. Klin Mgl Augenheilk 153:795, 1968.

2. Roberts W: Hematoma of the orbit. Am J Ophthalmol 40:215, 1955.

3. Whitwell J: Spontaneous hematoma of the orbit. Brit J Ophthalmol 40:250, 1956.

4. Wolter JR, Leenhauts JA, Coulthard SW: Clinical picture and management of subperiosteal hematoma of the orbit. J Pediatr Ophthalmol 13:136, 1976.

5. Cullen GCR, Luce CM, Shannon GM: Blindness following blowout orbital fractures. Ophthalmic Surg 8:60, 1977.

6. Fasanella RM: Eye Surgery: Innovations and Trends, Pitfalls, Complications. Springfield, III., Charles C. Thomas, 1977, p 194.

10.3928/0191-3913-19780501-07

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