Infection control in long-term care facilities: the need for engagement.

DISCUSSION Retro-orbital hematoma is a sight-threatening condition. Older adults may already have established impairment of visual acuity in one or both eyes. Further visual loss may be catastrophic in terms of functional impairment and loss of independence. Animal models have suggested that irreversible visual loss may occur after 100 minutes. The etiology of reduced visual acuity includes direct optic nerve compression, central retinal artery ischemia, and compression of optic nerve venous drainage. The presence of ophthalmoplegia, an afferent pupillary defect, subconjunctival hemorrhage, and proptosis should raise suspicion of retro-orbital hematoma, especially in the context of trauma or abnormal clotting. Canthotomy and cantholysis are recommended as first-line treatment and reverse the threat of visual loss. Canthotomy involves incision of the lateral canthal tendon. Further disinsertion of the inferior crus of the lateral canthal tendon is referred to as cantholysis. The procedure can be performed quickly under local anesthesia. Only a small amount of blood may be expelled. The subsequent orbital decompression facilitates recovery of normal orbital circulation and restoration of visual acuity. The wound is usually left to heal by secondary intention. The use of acetazolamide may be used as an adjunct to ‘‘medically’’ reduce intra-orbital pressure further. This case highlights a complication arising from a situation familiar to all physicians caring for older adults: a traumatic fall in an anticoagulated patient. Recognition of retro-orbital hematoma formation is essential if irreversible visual loss is to be avoided. Mark Scott, MB ChB Alexander Thomson, MRCP Department of Elderly Medicine Salford Royal Hospital Salford, United Kingdom