Intraorbital haematoma during a commercial flight: a case report

Intraorbital haematoma is an uncommon clinical entity in healthy individuals which is generally caused by surgery or trauma around the orbit, vascular malformations, increased venous pressure, valsalva maneuver, bleeding disorders, infection, inflammation, neoplastic or non-neoplastic orbital lesions and sinusitis. It may also occur secondary to intense paroxysmal cough, valsalva maneuver, during sickle cell crisis, general anaesthesia and barotrauma [1-5]. The symptoms are; sudden onset of retroorbital pain, proptosis, acute visual loss, chemosis and diplopia which occurs abruptly or gradually [6,7]. The diagnosis is confirmed by CT, MRI and laboratory examinations. Haematoma is hyperdense at early periods and its hyperdensity decreases at late periods in CT while MRI shows hyperintensity in T2 images and intermediate signal intensity on T1 images at hyperacute period. T1 and T2 images become hypointense at chronic period when the haematoma liquefies. Cerebral angiography is also useful to diagnose vascular anomalies, if needed. [1,5,6,8].

Airline travel is safe and reasonably comfortable but many factors including psychological stress, jet lag, and pre-existing diseases can affect a small number of passengers to become sick [9,10]. The etiology of the haemorrhage in this case can be explained by two hypotheses. First of all; psychological stress might have caused a systemic hypertension or valsalva maneuver which led to an increase in systemic and orbital venous pressure [11]. Secondly; sudden changes in cabin pressure might have caused barotrauma. Several cases of intraorbital haematoma have been reported in scuba divers suffering barotrauma [12-15]. This form of barotrauma is not from a sudden increase in cranial and orbital venous pressure, but rather a fall in pressure in the diver’s mask leading to a suction effect on the orbital contents and an increase in the pressure differential between the veins and the orbital soft tissues. In the history of the patient there was sudden onset of painful swelling in the right eye while aircraft was descending for landing. Diving barotrauma usually occurs during ascent because of a decrease in diver’s mask pressure whereas haematoma occurred during descent in this case, so we thought that increased orbital venous pressure caused by a valsalva maneuver is a more likely etiology for our patient.

If the clinical presentation and imaging features are consistent with a diagnosis of intraorbital haemorrhage and the vision is not compromised then a conservative approach can be adopted because in many patients blood resorbs without sequelae. Corticosteroids are the first line of treatment in intraorbital haemorrhages [1]. If the patient has visual loss or optic nerve involvement which reveals itself with afferent pupillary defect or dyschromatopsia, orbital decompression surgery or needle aspiration should be the first choice of treatment [7,16]. Intraorbital haemorrhage cases may require surgical or endoscopic decompression if the mass effect persists in spite of medical treatment [1,7]. Drainage of haematoma can be considered if the vision is compromised, if there is relative afferent pupillary defect or if proptosis is severe with the risk of corneal exposure. This can be performed in cases with spontaneous orbital haematoma, orbital haematoma associated with extraocular muscles or orbital floor implants. Haematoma should be drained and implant should be removed to avoid recurrence of bleeding with orbital floor implants [1,7-17]. Our patient’s clinical presentation and imaging features were consistent with a diagnosis of limited subperiostal intraorbital haematoma. We observed mild increase in IOP, proptosis and diplopia. Visual acuity was not compromised. We adopted conservative approach with close observation because haematomas without any visual disturbance have good prognosis and usually resolve without significant sequelae in a week or a month [1,7].