Orbital compartment syndrome: Pearls and pitfalls for the emergency physician

Abstract

Orbital compartment syndrome (OCS) is a rare, vision‐threatening diagnosis that requires rapid identification and immediate treatment for preservation of vision. Because of the time‐sensitive nature of this condition, the emergency physician plays a critical role in the diagnosis and management of OCS, which is often caused by traumatic retrobulbar hemorrhage. In this review, we outline pearls and pitfalls for the identification and treatment of OCS, highlighting lateral canthotomy and inferior cantholysis (LCIC), a crucial skill for the emergency physician. We recommend adequate preparation for the diagnosis and procedure, early consultation to ophthalmology, clear and thorough documentation of the physical examination, avoidance of iatrogenic injury during LCIC, and complete division of the inferior canthal tendon. Emergency physicians should avoid failing to make the diagnosis of OCS, delaying definitive surgical treatment, overrelying on imaging, failing to decrease intraocular pressure, and failing to exclude globe rupture. The emergency physician should be appropriately trained to identify signs and symptoms of OCS and perform LCIC in a timely manner.

Prehospital canthotomy: A sight‐saving procedure in case series

“…However, it requires additional training; retrobulbar haemorrhage is not essential in diagnosing OCS; its use does not add to the clinical picture and will unlikely change management 6 while potentially prolonging clinical assessment. Point‐of‐care ultrasound should not dissuade retrieval clinicians from performing LCC 7 and we do not advocate for its use. Computed tomography (CT) features include proptosis, tenting of the posterior globe and optic nerve stretching, defined by 20% increase in length of the optic nerve relative to contralateral side 8 .…”

Retrospective Cohort Study of Frequency and Patterns of Orbital Injuries on Whole-Body CT with Maxillofacial Multi-Slice CT

“…One of the major challenges in orbital trauma imaging is identifying injuries that may lead to orbital compartment syndrome (OCS), a condition characterized by elevated intraorbital pressure which can lead to permanent loss of vision in as little as 100 min via retinal or optic nerve ischemia [28]. Imaging signs hinting to elevated intraorbital pressure are proptosis, the elongation of the optic nerve, and a characteristic deformation of the globe referred to as globe tenting.…”

Case of Orbital Compartment Syndrome Post Cardiac Arrest

“…Prompt action regardless of the mechanism was taken based on our physical exam findings. If globe rupture is unlikely, it is reasonable to delay imaging and opt to perform the procedure and preserve vision [ 8 ]. This case is a reminder that it is crucial to identify signs of OCS in any possible setting and preparedness of the emergency medicine physician to perform LCIC.…”

“…The volume itself is confined by the orbital wall, orbital septum, and tarsal plate and intraocular pressure (IOP) is normally 8-21 mmHg [3][4][5][6]. Significant assault including but not limited to hemorrhage, abscess, tumor, orbital edema, or emphysema, or orbital cellulitis can lead to rapid rise in IOP >30 mmHg leading to ischemia and eventually irreversible vision loss [3,7,8]. Retinal ischemia for more than 90-120 minutes' leads to high risk for permanent blindness and therefore, must be addressed immediately without any delay due to imaging [6,8].…”

“…Significant assault including but not limited to hemorrhage, abscess, tumor, orbital edema, or emphysema, or orbital cellulitis can lead to rapid rise in IOP >30 mmHg leading to ischemia and eventually irreversible vision loss [ 3 , 7 , 8 ]. Retinal ischemia for more than 90-120 minutes’ leads to high risk for permanent blindness and therefore, must be addressed immediately without any delay due to imaging [ 6 , 8 ]. Diagnosis of orbital compartment syndrome (OCS) is clinical and typically presents with the following: proptosis, ophthalmoplegia, relative afferent pupillary defect (RAPD), tense globe, tight eyelids in partially retracted position, elevated IOP, papilledema, optic atrophy, cherry red macula, venous congestion, or central retinal artery pulsation on fundoscopy [ 3 , 7 , 9 - 10 ].…”