Recurrent Self-Induced Nontraumatic Orbital Emphysema Causing Orbital Compartment Syndrome with Optic Nerve Dysfunction

Abstract

The majority of cases of orbital emphysema are due to trauma. Complications are rare, and therefore, the need for surgical intervention is uncommon. We present the first case of which we are aware in which nontraumatic orbital emphysema led to orbital compartment syndrome and subsequent optic nerve dysfunction. The patient underwent emergency needle decompression. A 51-year-old man presented to the Emergency Department with right-sided unilateral proptosis, reduced visual acuity, and binocular diplopia. This occurred after performing a Valsalva manoeuvre with no history of head trauma. He also mentioned that over the past year he had experienced multiple episodes of transient proptosis occurring after Valsalva manoeuvres. Visual acuity in the right eye was reduced to 6/21. A relative afferent pupillary defect was present and intraocular pressure (IOP) was 12 mmHg. The CT scan showed significant orbital emphysema in the medial aspect of the right orbit. Needle decompression was performed resulting in immediate resolution of his symptoms. This case demonstrates that, in cases of orbital emphysema, a lack of a history of trauma and a normal IOP cannot always be used to rule out serious pathology.

Lateral Canthotomy and Cantholysis for Spontaneous Retrobulbar Hemorrhage With Normal Intraocular Pressures: Case Report and Review of the Literature

“…4 While helpful in many instances, tonometry may not be a reliable diagnostic tool in all situations, as some cases show that IOP measurements do not correlate with the severity of the patient's clinical picture. [19][20][21][22] In this case, the patient's right eye IOP was 21 mmHg, while the left eye IOP was 18 mmHg. While measured IOP variability does exist between both eyes, the difference is typically small.…”

Orbital Emphysema as a Result of Chest Tube Placement for Recurrent Pneumothorax

“…Orbital emphysema is extremely rare in the absence of preceding trauma. A review of the literature identifies only a handful of cases in the absence of periorbital injury, and even fewer cases secondary to pneumothorax or iatrogenic factors such as chest tube thoracostomy [8][9][10][11]. Retrospective studies suggest that approximately 1 in 5 chest tube insertions for pneumothorax result in subcutaneous emphysema, but the phenomenon in which the subcutaneous air infiltrates soft tissue compartments of the neck and spreads to the face and eyes is comparatively scarce [12][13][14].…”

“…Treatment is aimed at preventing orbital compartment syndrome, a sight-threatening condition that can occur due to progressive orbital emphysema, leading to increased intra-orbital pressure. This increased pressure can compress the optic nerve or its vasculature, which can impede perfusion of the central retinal artery, resulting in loss of vision [2,7,11]. Management for orbital emphysema depends on close observation for orbital signs.…”

“…Management for orbital emphysema depends on close observation for orbital signs. Initial assessment includes visual acuity, degree of proptosis, extraocular muscle restriction, pain with eye movement, and intra-orbital pressure, for which intraocular pressure can be used as an index [7,11]. However, it should be noted that normal intraocular pressures do not exclude orbital compartment syndrome [11].…”

“…Careful monitoring for worsening signs of orbital involvement as well as prompt intervention are required to prevent permanent vision loss. Needle decompression or lateral canthotomy with or without cantholysis can be performed [7,17,11]. In addition, the use of "fish gill" incisions for the placement of corrugated drains has been described as a novel surgical technique for treating progressive orbital emphysema [18].…”