Subperiosteal hematoma is a rare complication of periorbital injury and can evoke critical visual defects. The estimated incidence of intraorbital hematoma is 0.3%, while orbital subperiosteal hematomas are less common [2]. In pediatrics, orbital subperiosteal hematoma accounts for less than 1% of space-occupying lesions [1]. There are reports of post-traumatic orbital subperiosteal hematoma in children; however, the youngest age reported is two years [3]. We report the successful management of subperiosteal orbital hematoma in an infant.
The orbital subperiosteal hematoma after trauma mostly occurs in pediatric patients [4]. A possible explanation is the weak adherence of periosteum to the orbital roof in young subjects [4]. Such hematomas can compress the optic nerve causing visual impairment that persists even after its evacuation [1]. In a patient managed conservatively, the soft tissue swelling resolved in five weeks, and the subperiosteal hematoma took a significantly longer duration of four months to resolve completely [5]. Chronic orbital subperiosteal hematomas can eventually turn into cholesterol granulomas through granulomatous reaction or bone lytic lesions [6]. Considering the above possible complications, timely surgical removal of the hematoma is recommended.
The management of intraorbital hematoma ranges from observation to needle aspiration or surgical evacuations. The treatment of choice, however, remains controversial. Many studies recommend early surgical interventions for rapid recovery and to prevent sequelae [7]. In contrast, other reports recommend observation to prevent surgical complications such as local infections and re-bleeding [8]. It is important to note that successful conservative treatment was reported in children older than ten years who were not in the critical period for vision development [1, 6, 7].
Both blepharoptosis and conjunctival prolapse interfere with the pupillary axis, resulting in deprivation amblyopia in children under seven years of age [9]. Especially, physicians must consider this complication in all children under two years of age. In children with conjunctival prolapse, the blockage of pupillary axis causes visual deprivation and stimulus deprivation amblyopia. This type of amblyopia develops in the cases of congenital ptosis and congenital cataract. The best corrected visual acuity of an infant with eyelid swelling who was not treated for a short duration of six days reduced to below 0.125 [10]. Also, stimulus deprivation amblyopia can be resistant to treatment, leading to poor visual prognosis.
The relationship between congenital ptosis and strabismus is well reported. The incidence of strabismus in simple congenital ptosis is approximately 9.9% and is higher compared to its incidence in the general population (1% to 5%) [9]. It is suggested that strabismus results from visual occlusion and disruption of binocularity by the ptotic eyelid [9]. Therefore, careful examinations are essential in patients presenting with ptosis after trauma.
In summary, we describe the case of an infant who suffered subperiosteal orbital hematoma with intracerebral hemorrhage. Thus, in infants presenting with subperiosteal hematoma, it is important to rule out a combined intracerebral lesion. Early intervention is crucial to prevent stimulus deprivation amblyopia and strabismus. Occlusion therapy for amblyopia and close follow-up are recommended for such children after the initial management.