Retrobulbar Hematoma: CT Predictors of Vision Loss After Trauma
Key Takeaways
- The authors reported 52 retrobulbar hematoma cases among 7,671 registry patients (0.7%), although the paper inconsistently describes the denominator as head-and-neck trauma versus midface fracture cases and gives differing study dates.
- Cases were seen most often in middle-aged men and older women, with anticoagulant or antiplatelet exposure overrepresented among patients with retrobulbar hematoma.
- Fractures clustered around the orbital floor, medial wall, and zygomatic surface, and poorer visual outcome was associated with intraconal location, optic nerve contact, orbital floor fracture, higher retrobulbar hematoma-to-orbit volume ratio, and aspirin exposure.
- Decompression was used in 15 of 52 cases; 34 patients were discharged with intact vision, but discharge visual-acuity data were missing for 11 patients, 2 had blindness, and 4 died in hospital from severe trauma or organ failure.
At a German maxillofacial trauma center, investigators conducted a single-center retrospective observational analysis of the Dortmund Maxillofacial Trauma Registry. The authors reported 52 retrobulbar hematoma cases among 7,671 registry patients (0.7%), although the paper inconsistently describes the denominator as head-and-neck trauma versus midface fracture cases and gives differing study dates. All included patients underwent computed tomography (CT). Fractures were classified with the Arbeitsgemeinschaft für Osteosynthesefragen (AO) system, and CT-based 3D segmentation characterized hematoma dimensions, quadrant location, relation to the muscle cone, optic nerve and globe contact, and the retrobulbar hematoma-to-orbit volume ratio. The analysis used descriptive comparisons, neural network modeling, receiver operating characteristic (ROC) analysis, and multivariable linear regression.
Retrobulbar hematoma was identified in 52 of 7,671 patients, or 0.7%. Cases were seen most often in middle-aged men and older women, and 15 of 52 patients were taking anticoagulant or antiplatelet therapy, including aspirin, novel anticoagulants, and vitamin K antagonists. Fractures clustered around the orbital floor, medial wall, and zygomatic surface, with just over half of AO level 3 fracture sites concentrated in five zones; the hematomas were predominantly extraconal, and optic nerve contact occurred in a minority of cases.
Most patients were managed without decompression, but 15 of 52 underwent surgical decompression, 34 were discharged with intact vision, and blindness occurred in 2 patients. The authors' neural network analysis identified orbital floor fracture zone, intraconal location, globe contact, higher retrobulbar hematoma-to-orbit volume ratio, and aspirin or other antithrombotic exposure as poor-outcome signals rather than established causes. ROC analysis for the volume-ratio marker yielded an AUC of 0.824 (95% CI, 0.659-0.988; p < 0.001), with an optimal cutoff of about 0.0544, 100% sensitivity, and about 72.5% specificity. In multivariable analysis, optic nerve contact was the only statistically significant predictor of worse outcome (B = -0.288, SE = 0.119, beta = -0.452, p = 0.020).
Interpretation is limited by the retrospective, single-center design at one German trauma center, which may not generalize to other settings. Explicit discharge visual-acuity data were missing for 11 of 52 patients, documentation of symptom-onset-to-surgery timing was often incomplete, and intraocular pressure measurements were unavailable. The authors also noted that the overall multivariable regression model was not statistically significant, and that the ROC and neural-network signals were based on limited poor-outcome events and were presented as needing larger multicenter validation.
Within this German trauma-center cohort, poorer visual outcomes tracked more with anatomic CT features than with demographic variables, especially intraconal location, optic nerve contact, orbital floor involvement, and greater relative hematoma volume. The authors presented volumetric CT analysis and a checklist-oriented workflow as tools that may support recognition and triage while calling for broader multicenter validation. Retrobulbar hematoma remained uncommon in this population, and the reported risk pattern centered on orbital anatomy rather than patient profile alone.
Clinician Questions
Which trauma patients were included in the retrobulbar hematoma registry analysis?
The analysis covered patients with head and neck trauma treated in the Dortmund Maxillofacial Trauma Registry from 1 January 2018 to 31 March 2025, and all included patients had CT scans. The findings therefore reflect a single German trauma-center population rather than every patient with orbital trauma in other settings.
How did the investigators define and measure retrobulbar hematoma anatomy on CT?
Investigators used CT-based 3D segmentation, divided the orbit into four quadrants, assessed whether each hematoma was intraconal or extraconal, recorded contact with the optic nerve and globe, and calculated the retrobulbar hematoma-to-orbit volume ratio. Those anatomic CT features formed the framework the analysis linked to visual prognosis.
What makes the visual-outcome analysis in trauma-related retrobulbar hematoma hard to interpret from this registry alone?
The study was retrospective and single-center, discharge visual-acuity data were incomplete for part of the cohort, symptom-onset-to-surgery timing was often not documented, and intraocular pressure data were unavailable. The overall multivariable regression model also was not statistically significant, which limits confidence in how broadly the reported prognostic pattern can be applied beyond this dataset.