Preseptal (septum) hematoma

Ear Nose | Otorhinolaryngology | Preseptal (septum) hematoma (Disease)


The orbital septum is a fibrous sheath that arises from the periosteum of the orbital rims. Superiorly, the orbital septum descends and fuses with the levator aponeurosis, whereas inferiorly, the septum ascends and fuses with the capsulopalpebral fascia. In both the upper and lower eyelids, the orbital septum creates two anatomical layers, the preseptal and postseptal spaces.

Causes and Risk factors

An acute hemorrhage in the preseptal space, while dramatic in appearance, may not be as vision-threatening as a postseptal hemorrhage. Bounded anteriorly by the septum, the postseptal orbital space can accumulate blood and create a compartment syndrome, thereby damaging the enclosed structures - most important, the optic nerve and the blood supply to the eye. To manage a patient with an orbital hemorrhage, the anatomical localization of the blood is essential.

Diagnosis and Treatment

If the orbital hemorrhage occurs in the preseptal space, the clinician has the option of observing the hematoma or draining it. If the preseptal hematoma is expanding rapidly, then making a small drainage incision would be acceptable therapy. However, if the hemorrhage is stable, observation is appropriate, provided that the patient is not worsening clinically.

A postseptal orbital hemorrhage is a much more precarious situation for the patient. The clinician should be prepared to release postseptal orbital blood using a canthotomy and cantholysis. If an expanding postseptal orbital hemorrhage is missed, the results can be deleterious to the patient’s visual potential in the affected eye. To ensure the best possible outcome for a patient with an orbital hemorrhage, the clinician must proceed with evaluation promptly. Determining the cause of the orbital hemorrhage will aid in the prioritization of procedures to relieve the hemorrhage.

A preseptal hemorrhage can be drained through an eyelid incision, while a vision-threatening postseptal hemorrhage calls for frequent monitoring and possible orbital evacuation. The clinician should have a very low threshold for performing a canthotomy and cantho-lysis, since the consequences of waiting can be harmful to the patient’s vision and ocular motility. ...