Retrobulbar haemorrhage

What is retrobulbar haemorrhage?

  • Rapidly progressing haemorrhage into the retrobulbar space which is rare but potentially sight threatening.
  • Retrobulbar haemorrhage causes a rapid rise in intraorbital volume and pressure.
  • If not treated it can quickly lead to retinal ischaemia and infarction resulting in permanent visual impairment or complete visual loss.

When to consider retrobulbar haemorrhage?

From Royal Collage Ophthalmology

In any patient with blunt/penetrating orbital trauma or recent eye surgery with the following signs or symptoms

  • Severe eye pain
  • Rapid loss of vision
  • Nausea and vomiting (secondary to raised intra ocular pressure)
  • Tense, swollen eye lids
  • Orbital congestion
  • Proptosis
  • Relative afferent pupillary defect (RAPD)
  • Restricted eye movements
  • Peri orbital haematoma


Relative Afferent Pupillary Defect (RAPD)

Relative Afferent Pulliary Defect (RAPD) is also known as Marcu-Gunn Pupil. RAPD is demonstrated by the ‘Swinging-Flashlight Test’ as shown in the diagram. Where shining light into the unaffected eye causes bilateral pupillary constriction, but when shone into the effected eye both pupils dilate again.In retrobulbar haematoma this is due to traction/pressure on the optic nerve.

What to do if you suspect retrobulbar haemorrhage?

  • Ensure detailed eye examination is performed and documented including visual acuity.
  • Contact the Ophthalmology team on-call immediately  & start Lateral Canthotomy
  • The patient will almost certainly require CT head & facial bones but this should not take priority over Lateral Canthotomy & contacting Ophthalmology.
  • Ensure adequate analgesia is prescribed.
  • Involve a senior doctor as soon as a diagnosis of retrobulbar haemorrhage is suspected.

Lateral Canthotomy Guide – HERE


  • In the instance of retrobulbar haemorrhage secondary to trauma, consider the mechanism of injury and ensure patient is assessed for the presence of other injuries
  • Remember ‘Silver Trauma’ patients who may appear to have sustained a low risk mechanism of injury require a high level of clinical suspicion and early involvement of senior doctor.


References & Further reading

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