Sir,

Haemorrhagic complications following systemic thrombolytic treatment are well documented. However, bilateral orbital haematomata following thrombolysis represents an extremely rare complication.

Case report

A 32-year-old woman presented with sudden onset of dyspnoea 2 weeks after hemiarthroplasty following a fractured neck of femur. The patient was 6 weeks post-caesarean section following an uneventful pregnancy. Her past medical history included asthma and a severe scoliosis. She had no relevant family history.

The patient's condition deteriorated rapidly requiring intubation. Pulmonary embolism was confirmed with a computed tomography pulmonary angiogram (CTPA), intravenous thrombolysis (10 000 U Metaplase) given, and the patient transferred to the intensive therapy unit (ITU). After 2 days, the patient was noted to have left-sided chemosis and lid oedema, although pupil responses were normal. Following extubation 6 days later, she described decreased visual acuity and an ophthalmology opinion was sought.

On examination, visual acuity was perception of light in the left eye and 6/9 in the right eye. There was a left relative afferent papillary defect (RAPD) with proptosis of 4 mm and eye movements were moderately reduced superiorly and horizontally with a marked left exotropia. Mild reduction in right eye laevoversion was also noted. Intraocular pressures were 20 mmHg in the right eye and 21 in the left, and both discs were healthy with a cup/disc ratio of 0.2. No spontaneous venous pulsations were seen.

A computed tomography (CT) scan of the orbits (Figure 1) demonstrated bilateral proptosis secondary to bilateral superior subperiosteal haemorrhages. The subperiosteal haematomata lay superior to the superior recti, which were displaced inferiorly but there was no evidence of optic nerve compression radiologically.

Figure 1
figure 1

(a–d): Axial (a), coronal (b), oblique (left) (c) and oblique (right) (d), contrast-enhanced CT images through the orbits demonstrating bilateral superior subperiosteal orbital haematomata.

Full size image

The putative cause of the left optic neuropathy was the compression of the optic nerve within the orbit due to an acute haemorrhage following thrombolysis, possibly at the time when the lid oedema and chemosis were first noted. Given that ophthalmic review was 5 days post thrombolysis, the intraocular pressure was normal at this point and there was no evidence of central retinal artery occlusion, it was felt there would be no benefit from surgical decompression. The patient was managed conservatively with a decreasing dose of oral prednisolone starting at 60 mg/day reducing over 2 weeks.

At ophthalmologic review 6 weeks later, the patient had full resolution of proptosis with normal eye movement. Visual acuity had improved to 6/12 in the left eye, although the RAPD persisted.

Comment

Spontaneous intraorbital haemorrhage following thrombolytic therapy remains a rare complication with only limited cases reported.1, 2 It has been described following anticoagulation associated with endovascular procedures such as coronary artery stenting and intracranial aneurysm coiling3 and even following subcutaneous heparin treatment in two pregnant patients.4 Despite its rarity clinicians should be alert to the condition, particularly, in the intensive care setting, in non-conscious patients, and those with other severe comorbidities. The authors believe that this case represents only the second report in the English literature of spontaneous bilateral orbital haematomata following intravenous thrombolysis.5