Julia Elpers, Christopher Areephanthu, Peter J. Timoney, William R. Nunery, H.B. Harold Lee & Roxana Fu
Purpose: To compare the efficacy of the vertical lid split (VLS) to the standard lateral canthotomy and cantholysis (LC/C) for orbital compartment syndrome (OCS) in the cadaveric model.
Methods: Simulated OCS was achieved in seven fresh frozen cadaveric orbits. Orbital pressure (OP) was monitored in one control orbit and six interventional orbits. Initial OP was recorded before three right orbits underwent lateral canthotomy with superior and inferior cantholysis, and three left orbits underwent vertical lid split of the upper and lower eyelids. In all 7 orbits, OP was recorded for a total of 16 min. The main outcome measure was the amount of OP reduction at timed intervals.
Results: Beginning OP in the control orbit was 109 mmHg, and average initial OP of the LC/C and VLS orbits were 90 and 103 mmHg, respectively. The control orbit maintained high OP without intervention. One minute after LC/C, OP decreased an average of 58.7 mmHg (65.2%; range 48–65 mmHg). One minute following VLS, OP decreased an average of 63 mmHg (61.0%; range 39–102 mmHg). At 16 min, OP reduction in the LC/C orbits averaged 65.3 mmHg (72.6%; range 56–71 mmHg), and OP reduction in the VLS orbits averaged 78 mmHg (75.5%; range 54–121 mmHg). Both interventions produced a comparable reduction in OP.
Conclusions: Vertical lid split was found to be as effective as LC/C in reducing OP. The technical simplicity of the VLS lends itself well to utilization by physicians who are unfamiliar with eyelid surgery.
Dylan V. Stevens, Ann Q. Tran, Eleanore Kim
A 74-year-old man presented with a 10-day history of fever, cough, and progressive dyspnea. The patient was diagnosed with severe pneumonia related to COVID-19, after a positive polymerase chain reaction test and radiographic imaging (Fig A). The hospital course was complicated by respiratory failure requiring orotracheal intubation. Refractory hypoxia prompted increased levels of positive end-expiratory pressure (up to 18 cm H2O) and prone positioning. Upon supination, subcutaneous emphysema extended from the chest to the face, unilaterally in the conjunctiva (Fig B), and bilaterally around the eyelids (Fig C). Complete ophthalmologic examination did not reveal any evidence of orbital compartment syndrome or vascular occlusion. (Magnified version of Fig A–C is available online at www.aaojournal.org).
Prerana Kansakar & Gangadhara Sundar
Purpose: Vision loss after orbital surgery is one of the most dreaded complications faced by the orbitofacial surgeon. This literature review was conducted in an attempt to determine the risk factors for severe vision loss and discuss the applied anatomy related to various types of orbital surgery – orbital tumor excisions, orbital decompression, and post-traumatic orbital reconstruction.
Methods: A literature search was conducted via PubMed and Google Scholar. All cases of vision loss following orbital tumor biopsy or excision, orbital decompression, and orbital trauma reconstruction were reviewed.
Results: The incidence of postoperative blindness appears to be more after orbital tumor excisions (4.7%), compared to post-traumatic orbital reconstruction (2.08%) and orbital decompressions for thyroid orbitopathy (0.15%).
The causes of vision loss include ischemic optic neuropathy, traumatic optic neuropathy, retinal and ophthalmic artery occlusions, and orbital compartment syndrome.
Conclusion: Apart from careful patient selection, proper counseling about the risk of postoperative blindness is of utmost importance. Detailed preoperative treatment planning, meticulous atraumatic intraoperative dissection under direct visualization, with attention to the danger zones and vital structures, close intraoperative and postoperative monitoring, and urgent management of potentially reversible compressive causes of vision loss can improve outcomes.
Raed Shatnawi, Samar A. Shweiki, Arif O. Khan
A previously healthy 11-year-old girl presented with bilateral orbital compartment syndrome secondary to retrobulbar hemorrhages requiring emergency cantholysis. Four days earlier she had sustained head trauma without symptoms until her acute presentation. A basic hematologic profile was remarkable for a prolonged partial thromboplastin time, which did not completely correct with a 1:1 mixing study. This result raised suspicion for the most common acquired deficiency of clot stability, acquired factor VIII deficiency (acquired hemophilia A). Low factor VIII levels and the presence of autoantibodies against autologous factor VIII were confirmed. The child was treated daily with fresh frozen plasma and showed marked improvement over the ensuing days and weeks.
Matthew Kondoff, Georges Nassrallah, Michael Ross, Jean Deschênes
Retrobulbar hemorrhage (RBH) is a potentially sight-threatening complication of orbital fractures causing an orbital compartment syndrome (OCS). RBH causing OCS is regarded as a clinical diagnosis when evidence of optic nerve compression is found. Nonetheless, many patients with facial trauma will have received imaging by computed tomography (CT) on which there is documented RBH, with or without signs of OCS. The aim of this study was to identify the incidence and describe the outcomes of these CT-diagnosed RBH.
This is a retrospective chart review of patients with orbital fractures for which ophthalmology was consulted. Confirmation of orbital fracture and presence of an RBH on facial-bones CT was recorded. Patient demographics, proptosis, visual acuity, intraocular pressure and interventions received at initial visit and follow-up were recorded.
292 orbits with wall fractures were identified. 94 (32.2%) were documented by CT to have RBH. Of these orbits, only one (1.1%) was diagnosed with OCS receiving canthotomy and cantholysis. 53 orbits with initial CT-diagnosed retrobulbar hematoma were seen in follow-up a week or more later, none of which had developed signs of OCS or needed medical or surgical intervention for OCS.
RBH is a frequently reported finding on CT in cases of orbital fractures. In this study, almost all of these CT-diagnosed RBH did not develop OCS initially or by the time of follow-up. CT presence of RBH is not an accurate predictor for OCS, and the diagnosis and treatment of OCS should be directed clinically.
Hamill, Eric B.; Weber, Adam C.; Patel, Kalyani R.; Yen, Michael T.
Orbital compartment syndrome poses a significant risk for vision loss if not promptly treated. The authors report a patient with neuropsychiatric systemic lupus erythematosus presenting with bilateral orbital compartment syndrome and rapid decompensation leading to uncal and tonsillar herniation. While extremely rare, bilateral orbital compartment syndrome should prompt consideration of systemic etiologies including neuropsychiatric systemic lupus erythematosus.
Sonia Huang, Michelle T. Sun, Garry Davis, Jude Fitzgerald, Dinesh Selva & Tim Henderson
A 39-year-old male developed bilateral periorbital oedema and tense orbits in keeping with orbital compartment syndrome (OCS) shortly after presenting to the emergency department for uncontrollable epistaxis. Bilateral lateral canthotomy and inferior cantholysis was performed within 30 minutes of onset, with the left side further decompressed via superior cantholysis. Computed tomography demonstrated bilateral proptosis and optic nerve stretch, but no intraorbital haemorrhage or haematoma. Laboratory findings were consistent with disseminated intravascular coagulation (DIC) and sepsis of unknown origin. The right visual acuity recovered to 6/6 -2 from counting fingers, but the left eye failed to improve beyond light perception. This unique case of OCS is the first associated with DIC which had no evidence of intraorbital haemorrhage.
Rodríguez-Cabrera, Lourdes; Rodríguez-Loaiza, José L.; Tovilla-Canales, José L.; Zuazo, Francisca
Three patients with a history of previous pars-plana vitrectomy, 2 of them with perfluoropropane, and 1 with sulfur hexafluoride used, experienced eyelid swelling and pain after travelling to a higher altitude city. Gas was found in the orbit and periocular tissues, causing orbital compartment syndrome in 2 of the patients. The gas persisted on these patients despite surgical intervention, so hyperbaric oxygen therapy was advised. One patient refused, the other patient responded well to this therapy and the gas disappeared. The patient without an orbital compartment syndrome made a full recovery without needing medical or surgical intervention.
Andrew T. Strand, Craig N. Czyz & Amanda Gibson
This article evaluates the use of a “canthal cutdown” technique in orbital compartment syndrome in a cadaveric model. Twelve cadaver orbits were used to simulate orbital compartment syndrome using a blood analog solution. Two pressure probes, in different orbital locations, were used to monitor orbital pressure. Pressure was monitored during successive procedures: canthotomy, cantholysis, and canthal cutdown. Orbits were then re-injected with solution, simulating an active orbital hemorrhage, and pressure measurements were recorded over a 10-minute duration. No statistically significant difference was found between the two orbital pressure monitoring devices at each measurement point (p = 0.99). Significant pressure reductions, for both probes, were observed after canthal cutdown compared to initial measurement after injection of 20 mL blood analog (p < 0.001 and p = 0.005). When comparing the orbital pressure following canthotomy and inferior cantholysis versus canthal cutdown, the cutdown procedure provided an additional 74% in orbital pressure reduction (p =0.01). After re-injection of 10 mL of solution and 10 minutes of egress, pressure returned to baseline (probe 1: baseline 7 mm Hg vs. post-cutdown at 10 minutes 7 mm Hg; p = 0.83; and probe 2: 5 mm Hg vs. 5 mm Hg; p= 0.83). The canthal cutdown technique provides further reduction in orbital pressure versus canthotomy and cantholysis alone. The technique may be effective for treatment of static orbital compartment syndrome and temporizing treatment of compartment syndrome from active orbital hemorrhages.
Leung, Victoria C.; Hussain, Ahsen; Krings, Timo; DeAngelis, Dan
An 89-year-old woman presented after blunt injury to the left orbit from a fall. Examination findings were suggestive of left-sided orbital compartment syndrome, unresponsive to emergent lateral canthotomy and cantholysis. CT revealed a left-sided orbital floor blowout fracture involving the infraorbital canal, with a large maxillary and infraorbital hematoma. Angiography revealed a pseudoaneurysm supplied by the infraorbital artery. Interventional neuroradiology successfully achieved hemorrhage control by endovascular obliteration of the parent artery close to the pseudoaneurysm. To our knowledge, this is the first reported case of successfully managing active intraorbital hemorrhage causing orbital compartment syndrome by endovascular vessel sacrifice of an infraorbital artery pseudoaneurysm.