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Case Reports and Small Case Series
January 1998

Orbital Hemorrhage in the Nonoperated Eye as a Complication of General Endotracheal Anesthesia

Arch Ophthalmol. 1998;116(1):105-106. doi:

We report an unusual complication of general endotracheal anesthesia. A healthy 74-year-old woman suffered a subperiosteal hemorrhage in the superior right orbit after general endotracheal anesthesia for a combined phacoemulsification, intraocular lens implantation, and trabeculectomy in the left eye. Vision was uncompromised and the hematoma resolved without surgical intervention.We conclude that recovery from general endotracheal anesthesia is capable of raising intravascular pressures and may have led to hemorrhage within a presumed normal orbit in our patient. Consideration must be given to this potential complication in patients with lesions that may predispose to intraorbital hemorrhage.

Report of a Case

A 74-year-old healthy woman underwent left phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy. She had been experiencing frequent painful spasms from postherpetic neuralgia and was concerned about move-ment during the procedure. General endotracheal anesthesia was therefore provided at her request.

During the procedure, erythromycin ophthalmic ointment was placed in the right eye and the eye was then taped closed. The procedure was completed in 45 minutes and was uneventful. The highest documented intraoperative blood pressure was 160/80 mm Hg. The patient experienced a short episode of coughing during extubation.

The following morning, orbital swelling and ecchymosis of the upper eyelid was present in the right (nonoperated) eye. On questioning, the patient reported having noted painless right orbital swelling approximately 30 minutes after surgery. Visual acuity was 20/25 OD (unchanged from her preoperative baseline). There was no afferent pupillary defect and color vision was normal. Motility was partially restricted in all fields of gaze and there was 8 mm of axial proptosis. Intraocular pressure in the right eye was elevated to 36 mm Hg, above her baseline of 21 mm Hg.

A preoperative complete blood cell count was normal. Platelet count was 190×109/L. Coagulation studies were not performed. No antiplatelet medications were used in the perioperative period. Because there were no signs of compressive optic neuropathy, no therapeutic intervention was undertaken. Magnetic resonance imaging (Figure 1) was ordered to look for a lesion that might have predisposed to hemorrhage. The magnetic resonance image demonstrated a subperiosteal collection of blood in the superior right orbit; however, no other abnormalities were present. The proptosis resolved gradually during the next 4 weeks with no residual deficits. Fortunately, in our patient the hemorrhage occurred in the orbit of the nonoperated eye; otherwise, we may have erroneously believed our procedure was its cause.

Left, Coronal magnetic resonance image with gadolinium enhancement and incomplete fat suppression demonstrates subperiosteal blood (arrow) in the right orbit. Right, Parasagittal view demonstrates the hemorrhage displacing the superior rectus muscle inferiorly (arrow).

Left, Coronal magnetic resonance image with gadolinium enhancement and incomplete fat suppression demonstrates subperiosteal blood (arrow) in the right orbit. Right, Parasagittal view demonstrates the hemorrhage displacing the superior rectus muscle inferiorly (arrow).


Spontaneous orbital hemorrhage after general endotracheal anesthesia has been previously reported.1,2 Hemorrhage associated with a Valsalva maneuver has been reported during labor,3 weight-lifting,4 and with the elevation of intravenous pressure that occurs during external cardiac massage and strangulation. Other conditions associated with spontaneous orbital hemorrhage include cavernous hemangioma, lymphangioma, varix, idiopathic inflammatory pseudotumor, hypertension, hemophilia, blood dyscrasias, leukemia, renal disease, vascular disease, and scurvy.

A Valsalva maneuver causes increased intravascular pressure that is transmitted to the orbital veins, which lack valves. Venous distension may then lead to hemorrhage. Krohel and Wright3 differentiated venous hemorrhage and arterial hemorrhage by the severity and acuity of symptoms. They believed that most venous hemorrhages resolved spontaneously without sequelae. However, arterial hemorrhage, such as might be caused by trauma or arteriosclerosis, frequently required surgical drainage because of optic nerve compression.

Hemorrhage beneath the periosteum has been reported4 but is less common than hemorrhage within the soft tissues of the orbit. When surgical drainage of blood is indicated, imaging studies can be helpful in directing the operative approach and should be considered.

The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the US Navy, Department of Defense, or US Government.

Corresponding author: Kerry E. Hunt, MD, National Naval Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889.

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Anderson  KKLarson  NHSag-Rumley  SAHamed  LM Spontaneous orbital hemorrhage during general anesthesia and arthroplasty.  J Clin Anesth. 1994;6145- 147Article
Krohel  GBWright  JE Orbital hemorrhage.  Am J Ophthalmol. 1979;88254- 258
Katz  BCarmody  R Subperiosteal orbital hematoma induced by the Valsalva maneuver.  Am J Ophthalmol. 1985;100617- 618