Right Spontaneous Retrobulbar Hemorrhage after Endoscopic Retrograde Cholangiopancreatogram (ERCP) in a Patient with Liver Cirrhosis

Abstract

Objective/Purpose: Acute retrobulbar hemorrhage is a sigh-threatening complication of blunt eye trauma and orbital surgery, requiring prompt recognition and treatment.Spontaneous retrobulbar hemorrhage however is extremely uncommon. We describe a spontaneous retrobulbar hemorrhage occuring after endoscopic retrograde cholangiopancreatogram in a patient with coagulation abnormalities. Materials/Patients: A 45-year-old man, with chronic hepatitis B-related liver cirrhosis, underwent deceased donor liver transplantation on the 1st of January 2013. The procedure was complicated by biliary anastomotic stricture, presenting with biliary enzymes. Endoscopic retrograde cholangiopancreatogram (ERCP) was performed on day 37 after liver transplantation. 1 hour after procedure, the patient noted right eye pain and loss of vision. There was associated headache, nausea and vomiting. Methods: On ophthalmological assessment, Snellen Chart visual acuity was count fingers at half a metre in the right eye and 20/30 in the left eye. Intraocular pressure using tonopen was right eye > 55 mmHg and left eye 19 mmHg. The right eye was proptotic with complete ptosis. Pupils were equal and reactive to light with no relative afferent pupillary defect.Right eye movement was restricted in all directions with preservation of normal saccades. Emergency right lateral canthotomy and cantholysis was performed under local anesthesia by the bedside immediately. Results and Conclusion: Contrast CT scan of the orbit confirmed a large extraconal hematoma displacing the globe downwards and laterally.There was no evidence of abnormal vascular lesions in the brain or orbit. Screening for bleeding disorders revealed thrombocytopenia and prolonged APTT and PT, consistent with his underlying liver disease. In conclusion, ophthalmologists and general surgeons should be aware of this rare but devastating complication in patients with coagulation abnormalities. Prompt recognition and treatment is crucial to saving the eye.