If a retrobulbar hematoma leads to a tense, proptotic globe, emergency decompression should be considered.
If a retrobulbar hematoma in the cooperative patient results in blindness, the time window to release the intraorbital pressure is limited to around one hour measured from the onset of blindness. This could mean urgent treatment under local anesthesia even in the emergency room prior to further imaging.
Transcutaneous transseptal incisions may help evacuate the hematoma and release the periorbital pressure. Alternative methods such as transconjunctival pressure release and/or lateral canthotomy and inferior cantholysis should be considered according to patient condition.
An exception may be where there is a pulsating exophthalmos which may be a sign of carotid-cavernous sinus fistula. A fistula of this nature requires appropriate preoperative imaging.
Note: retrobulbar hematoma is one of the most severe postoperative complications in patients who have undergone orbital trauma and/or surgery. This is one reason why the surgeon has to assess appropriate vision as soon as possible after injury and/or surgery.