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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 974-976

Post-traumatic orbital subperiosteal hematoma presenting as proptosis with Curvularia keratitis

Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission24-Mar-2022
Date of Acceptance05-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Saroj Gupta
All India Institute of Medical Sciences, Saket Nagar Bhopal, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_773_22

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A 13-year child presented with protrusion of the left eye (LE) with redness, pain, and diminution of vision following blunt head trauma. The best-corrected visual acuity (BCVA) in the LE was hand movement. On examination, LE had abaxial proptosis with lagophthalmos and severe exposure keratopathy. There was a large corneal ulcer with feathery margins and superficial brown pigmentation, confirmed as Curvularia spp. on microbiological assessment. A computed tomography (CT) scan of the orbit and brain demonstrated superior subperiosteal hematoma of the orbit and frontal epidural hematoma. Aspiration of blood from subperiosteal orbital hematoma resulted in an immediate reduction of proptosis. The epidural hematoma resolved spontaneously. Treatment with topical and systemic antifungal agents resulted in complete healing of the keratitis with a residual leucomatous corneal opacity. Emergency treatment of subperiosteal orbital hematoma through needle aspiration helps in the early resolution of proptosis, exposure keratopathy, and visual loss.

Keywords: Curvularia keratitis, exposure keratopathy, orbital subperiosteal hematoma, pediatric, traumatic proptosis

How to cite this article:
Gupta S, Sarkar D, Nechikaddu G. Post-traumatic orbital subperiosteal hematoma presenting as proptosis with Curvularia keratitis. Indian J Ophthalmol Case Rep 2022;2:974-6

How to cite this URL:
Gupta S, Sarkar D, Nechikaddu G. Post-traumatic orbital subperiosteal hematoma presenting as proptosis with Curvularia keratitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:974-6. Available from: https://www.ijoreports.in/text.asp?2022/2/4/974/358189

Blunt trauma can result in simultaneous epidural hematoma and subperiosteal orbital hematoma in young patients.[1] Proptosis may be the only presenting feature in such a scenario.[2] Subperiosteal orbital hematomas develop between bone and periosteum of the orbit due to rupture of subperiosteal blood vessels or due to extension of a subgaleal hematoma.[3] Such cases require immediate evaluation with computed tomography (CT) scan to delineate hematomas and rule out associated orbital fractures.[4]

Visual impairment may occur due to optic nerve compression or due to exposure keratopathy. Early diagnosis and appropriate management are vital to avert subsequent visual loss. Treatment includes observation for spontaneous resolution or emergency interventions including aspiration of hematoma and surgical evacuation when it is vision-threatening.[1],[2]

The index case highlights the clinical features, evaluation, and successful management of a unique case of traumatic unilateral proptosis secondary to orbital periosteal hematoma with Curvularia keratitis in a child.

  Case Report Top

A 13-year Indian male child presented in the emergency department with protrusion of the left eye (LE) for the last ten days. It was associated with redness, pain, watering, and diminution of vision in the LE. He had a history of blunt trauma head by road traffic accident 12 days back. There was no history of vomiting, seizure, epistaxis, or loss of consciousness. The best-corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and hand movements in the LE. On ocular examination, LE had abaxial proptosis of 5 mm with eyeball deviated down and out. The ocular movements were limited in all directions of gaze. The patient was unable to close the eye due to proptosis and chemosis leading to severe exposure keratopathy. The cornea appeared dry lusterless with an ulcer measuring 9 × 7 mm in size, with irregular margins and brownish pigmentation over the surface, with a streak of hypopyon [Figure 1]a. The anterior-chamber, pupil, and fundus details were not visible. Examination of RE was within normal limits.
Figure 1: (a) Clinical photograph at presentation showing abaxial proptosis of the left eye, conjunctival chemosis, and exposure keratitis with brown-pigmented plaque over the corneal surface. (b) Photograph at two weeks after treatment showing resolving keratitis. Pigmented plaque and corneal infiltrates are reduced in size. (c) Photograph at six weeks follow-up showing healed keratitis with vascularized corneal opacity

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Corneal scraping in potassium hydroxide showed hyaline septate hyphae. Melanized fungal fragments were seen on microscopy [Figure 2]a. Sabouraud's-dextrose-agar revealed olivaceous black wooly growth [Figure 2]b. Lactophenol cotton blue mount showed septate hyphae with brown conidiophores and brown conidia [Figure 2]c. The isolate was identified as Curvularia lunata.
Figure 2: (a) KOH wet mount of the corneal scraping showing hyaline septate hyphae and melanized fungal fragments. (b) Culture on Sabouraud's dextrose agar with chloramphenicol showing olivaceous black woolly growth with black pigment on the reverse side. (c) Lactophenol cotton blue mount showing septate hyphae with brown conidiophores and conidia

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CT scan of the brain and orbit showed a well-defined hypodense collection (measuring 4.5 × 2.4 × 2.0 cm), in the left anterior frontal region compressing the brain parenchyma, however, no midline shift was noted. Another well-defined hypodense collection was noted in the roof of the left orbit (measuring 3.4 × 2.9 × 1.7 cm) abutting the superior rectus and pushing the eyeball down and out, with no obvious compression of the optic nerve or bony fractures [Figure 3]a.
Figure 3: (a) CT scan of the brain and orbit sagittal view showing left frontal epidural hematoma (arrow) and superior orbital subperiosteal hematoma (arrow head). (b) CT scan at four weeks after aspiration of subperiosteal hematoma showing complete resolution of frontal epidural hematoma and small residual orbital subperiosteal hematoma (arrow head)

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An ultrasound-guided (USG) aspiration from the supraorbital collection was performed with an 18-gauge, 1.5-inch needle on the syringe, passed transcutaneously through the superior periorbital space, through the supraorbital notch. Aspiration of dark red blood (11 mL) resulted in an immediate reduction of proptosis.

The patient was started on topical 5% natamycin two hourly along with atropine-sulfate 1%, carboxymethylcellulose 0.5%, and oral Fluconazole 100 mg once a day for two weeks. Therapeutic scraping along with medications yielded favorable results with symptomatic improvement and apparent signs of healing in two weeks [Figure 1]b. Topical treatment was continued for four weeks. At six weeks of follow-up, there was complete resolution of proptosis, with a healed corneal ulcer leaving behind a leucomatous corneal opacity [Figure 1]c.

The frontal epidural hematoma was treated conservatively in liaison with a neurosurgeon, as there were neurological symptoms. A repeat CT scan performed at four weeks follow-up revealed, a small residual supraorbital hematoma along with resolved epidural hematoma [Figure 3]b.

  Discussion Top

Orbital hematomas are rare entities in subperiosteal or intraorbital locations.[5] Blunt trauma head is the most common cause of orbital subperiosteal hematoma.[1] Other causes include spontaneous hematoma in association with hematological disorders or due to an increase in intra-abdominal or intrathoracic pressure as in Valsalva maneuvers or scuba diving.[6] Subperiosteal hematoma is usually acute in onset, but delayed onset has also been reported.[3] The common site for hematoma is usually the orbital roof and it develops between bone and periosteum as the periosteum is not firmly adherent to the bone in superior orbit in children, making this zone vulnerable to damage and hematoma formation.[1],[3] It may or may not be associated with fracture of the orbital bones.

Association of frontal epidural hematoma with orbital subperiosteal hematoma is relatively uncommon.[2] The patient had a frontal epidural hematoma and superior orbital subperiosteal hematoma simultaneously following blunt trauma without bony fractures. CT scan is the preferred imaging modality, to delineate the size and extent of these hematomas, and also to rule out associated orbital wall fractures.[4] In a case of acute unilateral proptosis following blunt trauma, subperiosteal hematomas of the orbit should be ruled out.

Severe exposure keratopathy resulted in superadded Curvularia keratitis, which was managed conservatively. Corneal injury with sugarcane leaf is the most common predisposing factor for Curvularia keratitis.[7] In this case, the predisposing factor was due to exposure keratopathy which is of rare occurrence.

A conservative approach with observation and steroid therapy is indicated in orbital subperiosteal hematoma with no visual symptoms.[1] Patients with visual symptoms, proptosis, and exposure keratopathy require immediate intervention. In the index case, due to visual loss with severe proptosis and exposure keratopathy, urgent USG-guided needle aspiration of subperiosteal hematoma was performed which resulted in the reduction of proptosis. The remaining clotted blood resorbed spontaneously. Surgical evacuation is indicated when it is vision-threatening and there is a dry tap on needle aspiration.[1],[2]

Epidural hematoma is seen in 0.2–6% of patients with a traumatic head injury.[8] A conservative approach is employed when the hematoma is small with minimal midline shift and no focal neurological symptoms are present.[9] In our patient, the frontal epidural hematoma was managed non-surgically by close observation. To our knowledge, this is the first report of Curvularia keratitis in a patient with proptosis with exposure keratopathy following traumatic orbital subperiosteal hematoma.

  Conclusion Top

In a young patient presenting with unilateral proptosis following blunt trauma, subperiosteal orbital hematoma must be considered in the differential diagnosis. Evaluation with a CT scan helps in establishing the diagnosis. Early management of subperiosteal orbital hematoma through USG-guided needle aspiration helps in the resolution of proptosis and lagophthalmos. Microbiological workup of exposure keratitis is essential for the appropriate management and early resolution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kim UR, Arora V, Shah AD, Solanki U. Clinical features and management of posttraumatic subperiosteal hematoma of the orbit. Indian J Ophthalmol 2011;59:55-8.  Back to cited text no. 1
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Nayak N, Diyora B, Kamble H, Modgi R, Sharma A. Concomitant occurrence of subfrontal extradural hematoma and orbital subperiosteal hematoma: A rare entity. Neurol India 2010;58:637-41.  Back to cited text no. 2
[PUBMED]  [Full text]  
Wolter JR. Subperiosteal hematomas of the orbit in young males: A serious complication of trauma or surgery in the eye region. Trans Am Ophthalmol Soc 1979;77:104-20.  Back to cited text no. 3
Seigel RS, Williams AG, Hutchison JW, Wolter JR, Carlow TJ, Rogers DE. Subperiosteal hematomas of the orbit: Angiographic and computed tomographic diagnosis. Radiology 1982;143:711-4.  Back to cited text no. 4
Landa MS, Landa EH, Levine MR. Subperiosteal hematoma of the orbit: Case presentation. Ophthalmic Plast Reconstr Surg 1998;14:189-92.  Back to cited text no. 5
Choi HY, Han YS, Lee JS, Oum BS. Subperiosteal hematoma after surgical treatment for subarachnoid hemorrhage. Ophthalmic Plast Reconstr Surg 200;20:87-8.  Back to cited text no. 6
Khurana A, Chanda S, Bhagat P, Aggarwal S, Sharma M, Chauhan L. Clinical characteristics, predisposing factors, and treatment outcome of Curvularia keratitis. Indian J Ophthalmol 2020;68:2088-93.  Back to cited text no. 7
[PUBMED]  [Full text]  
da Costa LB Jr, de Andrade A, Henriques JG, Cordeiro AF, Maciel Cdo J. Traumatic bilateral intraorbital (subperiosteal) hematoma associated with epidural hematoma: Case report. Arq Neuropsiquiatr 2003;61:1039-41.  Back to cited text no. 8
Jamous MA, Abdel Aziz H, Al Kaisy F, Eloqayli H, Azab M, Al-Jarrah M. Conservative management of acute epidural hematoma in a pediatric age group. Pediatr Neurosurg 2009;45:181-4.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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