Lateral canthotomy and inferior cantholysis: an effective method of urgent orbital decompression for sight threatening acute retrobulbar haemorrhage

Intraoperative intraorbital bleeding: considerations from a collaborative and retrospective Italian study with a management algorithm proposal

Background: Intraoperative intraorbital bleeding is a rare but potentially catastrophic event that can lead even to blindness, if not treated promptly. The goal of surgery is to quickly reduce intraorbital pressure thus restoring normal visual function. Aim of our work is to propose a practical algorithm helping the surgeon in the setting of this critical event. Methodology: An Italian multi-institutional retrospective study was conducted. All the cases of intraoperative intra-orbital bleeding requiring at least some form of surgical management were analyzed. Cases simply managed conservatively were excluded from this analysis. Results: Sixteen cases were collected. Of these, 12 were initially treated with a medial wall orbital decompression, while 4 were treated via a lateral canthotomy and inferior cantholysis (LCC). Ten patients recovered completely. Four patients presented post-op sequelae (diplopia, enophthalmous and/or eyelid malpositioning). Two major negative outcomes (blindness) were observed. Conclusions: Timely surgical intervention is critical. According to the setting in which the bleeding occurs, different options are available. LCC is probably the most rapid maneuver that can be done to reduce intraorbital pressure. Anyway, if the patient is still in the OR and a complete ethmoidectomy yet done we advise, as first step, to perform a medial orbital wall decompression.

Spontaneous Retrobulbar Hemorrhage in a Previously Healthy Infant

Spontaneous retrobulbar hemorrhage is a rare yet vision-threatening condition. We reported a 5-month-old male infant with sudden onset of left eye proptosis with no prior history of getting vitamin K injection after birth. Head computed tomography scan revealed retrobulbar and intracranial hemorrhages. Laboratory results showed anemia, prolonged prothrombin and activated partial thromboplastin time, supporting the diagnosis of vitamin K deficiency bleeding. After the bleeding and clotting profile were stabilized, lateral canthotomy and cantholysis; and drainage following orbital decompression were successfully performed, yielded in a completely resolved proptosis. The right timing for surgery with the goal of releasing intraorbital pressure represent the merit of this paper. Our case also led to a crucial emphasis on vitamin K prophylaxis at birth.

Displaced Orbital Fractures with Concurrent Orbital Compartment Syndrome: A Case-Based Systematic Review

Orbital compartment syndrome (OCS) is an emergency that complicates intra-orbital, retrobulbar hemorrhage in most cases. Bony orbital decompression is an effective treatment for OCS, and displaced orbital fractures are protective. Nevertheless, in rare cases, OCS occurs despite a displaced orbital fracture. The aim of the current review is to present its pathophysiology and management based on what is published in the medical literature, and our center's experience. A systematic review of literature was conducted through PubMed, Medline, Embase, and Cochrane from inception through February 2021. The following search query was used: "orbital fracture" and "trauma" and "orbital compartment syndrome." Studies tackling the pathophysiology and management of concurrent displaced orbital fracture with OCS were included and a cohort of patients was constituted. A cohort of 18 cases reported in the literature were included (49.3 ± 30.6 years, 50% M). Given that OCS occurs with or without orbital fracture, pathophysiology of OCS is mostly explained by the division of the orbital fat into many compartments, due to the presence of Koorneef's fibrous septa. Management of OCS in such circumstances consisted of inferior-lateral canthotomy and cantholysis in 50% of cases, subperiosteal drainage with myringotomy in 22.2% of cases, subperiosteal drainage in 16.7% of cases, and complete lateral cantholysis in 16.7% of cases. Two cases who presented to our tertiary care center were also added to this review. Physicians should be aware that OCS can occur even with displaced fractures of the orbital cavity. When clinical suspicion is present, an emergent management is needed.

Orbital compartment syndrome: Pearls and pitfalls for the emergency physician

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.

Retrobulbar hematoma following the repair of an orbital wall fracture: a case series

Background

Retrobulbar hematoma is a rare complication after the repair of an orbital wall fracture, but the caution is required because the condition can cause blindness.

Case presentation

In this article, 3 cases of retrobulbar hematoma after the surgical repair of an orbital wall fracture are reported. In the first patient, the permanent loss of vision was involved, while in the second patient, the author was able to prevent loss of vision by performing immediate decompression after definite diagnosis and consulting with an ophthalmologist. In the third patient, there was no surgical treatment involved; he recovered on his own without major sequelae.

Conclusions

Retrobulbar hematoma is a very serious condition that can result in blindness. Thus, when it is recognized, every effort should be made to preserve the patient’s vision and prevent blindness.

Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature

Compartment syndrome can occur in many body regions and may range from homeostasis asymptomatic alterations to severe, life-threatening conditions. Surgical intervention to decompress affected organs or area of the body is often the only effective treatment, although evidences to assess the best timing of intervention are lacking. Present paper systematically reviewed the literature stratifying timings according to the compartmental syndromes which may beneficiate from immediate, early, delayed, or prophylactic surgical decompression. Timing of decompression have been stratified into four categories: (1) immediate decompression for those compartmental syndromes whose missed therapy would rapidly lead to patient death or extreme disability, (2) early decompression with the time burden of 3-12 h and in any case before clinical signs of irreversible deterioration, (3) delayed decompression identified with decompression performed after 12 h or after signs of clinical deterioration has occurred, and (4) prophylactic decompression in those situations where high incidence of compartment syndrome is expected after a specific causative event.

Orbital infarction syndrome after cerebral aneurysm surgery: A case series and literature review

To report the clinical characteristics and retinal abnormalities associated with orbital infarction syndrome after cerebral aneurysm clipping surgery.In this retrospective case series, we evaluated 4 cases of orbital infarction syndrome using fluorescein angiography, optical coherence tomography, and computed tomography images from January 2011 to May 2014. The medical records of these patients including age, sex, laterality of the eyes, visual acuity, intraocular pressure, duration of the operation, location of the aneurysms, and surgical method with the type of approach used to reach the aneurysmal lesions were evaluated.Aneurysms were located in either the anterior or the posterior communicating artery. Two patients had subarachnoid hemorrhage arising from a ruptured aneurysm, whereas 2 other patients had unruptured aneurysms. Clipping was performed by 3 different surgeons using the pterional craniotomy. The mean time interval from aneurysmal clipping to awareness of vision loss was 10.75 ± 13.8 days. In all patients, optic atrophy and irreversible deterioration of visual acuity ensued. Retinal edema, retinal vascular abnormality, or choroidal hypoperfusion was identified in these patients.Orbital infarction syndrome is a rare but devastating complication of brain aneurysm clipping surgery. The associated retinal ischemia is not only due to the involvement of the retinal vessels, but also the choroidal circulation.

Evidence-based algorithm for the management of acute traumatic retrobulbar haemorrhage

Retrobulbar haemorrhage (RBH) is a potentially blinding consequence of craniofacial trauma, but timely ophthalmic evaluation is difficult to obtain in some settings and clear standards for canthotomy/cantholysis are lacking. We have sought to develop an algorithm to identify vision-threatening traumatic RBH that requires emergent decompression. We retrospectively reviewed 42 consecutive consultations for RBH at a level-one trauma centre. Charts and imaging studies were analysed with attention to mechanism of injury, comorbid trauma, and ophthalmic findings. A total of 22 eyes were observed without intervention, 13 were treated pharmacologically, and seven by emergent canthotomy/cantholysis. No differences in standard trauma metrics were found among these groups. Lid oedema, ecchymosis, chemosis, subconjunctival haemorrhage, and ocular motility also failed to correlate with a need for surgical intervention. "Tight" eyelids (p<0.001), unilateral proptosis (p<0.001), and relative afferent pupillary defect (RAPD; p=0.029), however, all related to a need for canthotomy/cantholysis (Fisher's exact test). Tenting of the globe, which was the only radiographic finding to predict the need for surgery, was seen in just two of the seven cases that required decompression. Many of the traditionally emphasised clinical signs therefore fail to identify cases of RBH that require decompression. Our data support a simple three-factor decision tool. These are: relative proptosis, eyelids that are difficult to open with finger pressure, and presence of an RAPD in the traumatised eye. If all three are noted or if the patient has proptosis and tight lids in the absence of a large preseptal haematoma, he/she is likely to need surgical decompression. Tenting of the globe on computed tomography (CT), while a relatively rare finding, should also alert the physician of the need for intervention.

Efficacy of vertical lid split versus lateral canthotomy and cantholysis in the management of orbital compartment syndrome

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.

Pathophysiology and management of glaucoma and ocular hypertension related to trauma

Ocular trauma is a significant cause of blindness worldwide, particularly if associated with glaucoma. Direct damage from blunt or penetrating trauma, bleeding, inflammation, lens-related problems, orbital and brain vascular pathologies related to trauma, and chemical injuries may increase intraocular pressure and lead to traumatic glaucoma. Treatment may be as simple as eliminating the underlying cause in some conditions or management can be challenging, depending on the mechanism of damage. If proper management is not undertaken, visual outcomes can be poor. We discuss a broad spectrum of trauma-related mechanisms of intraocular pressure elevation, as well as their management.

Lateral Canthotomy and Cantholysis in Operations Iraqi Freedom and Enduring Freedom: 2001-2011

PURPOSE

To describe outcomes and associated ocular injuries of lateral canthotomy and cantholysis (LCC) as performed in combat ocular trauma.

METHODS

Data from the Walter Reed Ocular Trauma Database of patients requiring LCC during Operations Iraqi Freedom and Enduring Freedom was reviewed as a retrospective cohort. Primary outcome measures included final visual acuity (VA) and Ocular Trauma Score. Secondary outcome measures were associated injuries and timing of surgery.

RESULTS

Thirty-six LCCs were recorded on a total of 890 eyes (4.04 %) in the Walter Reed Ocular Trauma Database. Eighteen out of 36 eyes (50.00%) had a final VA of the affected eye of 20/200 or worse vision. From the initial available VA measured either at the time of injury or at Walter Reed Army Medical Center, 13 eyes (40.63%) had no change in VA, 15 eyes (46.88%) had improvement, and 4 (12.5%) had a decrease in VA (n = 32, data unavailable for 4 eyes). Ocular Trauma score 0-65 was noted in 14 (38.9%) and 66-100 (61.1%). Retinal detachment (6, 16.67%), optic nerve injuries (7, 19.44%), orbital fractures (20, 55.56%), and retrobulbar hematoma (25, 69.44%) were commonly associated injuries. Of the 36 LCC, 18 (50.00%) were performed as the first surgery performed at the combat support hospital, 13 (36.11%) as the second, 4 (11.11%) as the third, and 1 (2.78%) as the fourth.

CONCLUSIONS

The largest subgroup of patients had an improvement in VA associated with performance of LCC; however, half of patients remained with a final VA of equal to or worse than 20/200 due to severe ocular trauma.

Development of a novel simulation-based task trainer for management of retrobulbar hematoma

BACKGROUND

Retrobulbar hematoma (RH) is a rare but devastating complication of sinus surgery. It is treated initially with a lateral canthotomy and cantholysis at the bedside. Due to the high stakes and urgency of this complication, teaching this in the clinical setting is difficult. The objective of this study was to develop a cadaveric model for addressing this problem.

METHODS

A fresh-frozen human cadaveric model of RH was created using a Foley catheter to simulate elevated intraocular pressure. Residents who participated in an emergencies in otolaryngology-head & neck surgery "boot camp" were included in the study. A survey measuring confidence levels in performing lateral canthotomy and cantholysis was administered. After completing the skill station, a postintervention survey was administered to assess the confidence of the learner as well as fidelity and usefulness of the task trainer.

RESULTS

Thirty-three residents participated in the boot camp. Residents rated their confidence preintervention at 1.3/5, which suggests the majority were unable to perform the procedure. After using the model, residents rated their confidence at 3.5/5, which falls between basic knowledge and reasonably confident; this improvement achieved statistical significance (p < 0.0001). The fidelity of the model was rated 3.9/5; a score of 4 is defined as realistic. The residents rated the usefulness of the model as 4.7; a score of 5 is defined as very useful.

CONCLUSION

A cadaveric model of RH was successfully developed. This novel simulator was perceived to be useful, realistic, and effective by junior residents.

Visual outcomes after traumatic retrobulbar hemorrhage are not related to time or intraocular pressure

BACKGROUND

The paucity of literature regarding the role of time and intraocular pressure (IOP) when treating ocular compartment syndrome (OCS) has resulted in limited guidance for emergency physicians (EP).

OBJECTIVES

Our goals were to investigate the ideal time frame for lateral canthotomy, to understand the relationship between IOP and visual outcome, and to determine the impact of EP performance on visual acuity (VA).

METHODS

The study population included patients presenting over an 18-year period with traumatic retrobulbar hemorrhage (RBH) treated with lateral canthotomy. Efficacy was evaluated using visual outcome and IOP. Patients were grouped by time from injury and arrival to canthotomy. Procedures completed in the emergency department (ED) and by EPs were evaluated regarding visual outcome.

RESULTS

Sixty cases of RBH treated with lateral canthotomy were identified. Over two-thirds (43/60, 71.7%) were discharged with baseline vision. Lateral canthotomy lowered IOP from a median of 50.0 mmHg (IQR: 40.5, 61) preprocedure to 23.0 mmHg (IQR: 18, 27) post-procedure (p-value = 0.000001). No correlation was found between time, IOP, location, specialty of clinician, and visual outcome.

CONCLUSION

Lateral canthotomy is an effective at lowering IOP. Our data suggest that using time and IOP to predict procedural outcome is flawed. If OCS is suspected, lateral canthotomy should be considered and can be effectively performed by EPs. Neither the time of injury to ED presentation nor degree of IOP elevation should be factored into the decision of when to perform the procedure.

Orbital Compartment Syndrome: An Update With Review Of The Literature

Orbital compartment syndrome (OCS) is a potentially blinding condition characterized by a rapid increase in intra-orbital pressure. OCS is most commonly seen in the context of intra-orbital hemorrhage secondary to either trauma or surgery. A review of the literature indicates that better visual outcomes are achieved when interventions occur within the first 2 hrs. There are reports of visual recovery after a delay in management and consideration should be given to intervention even when presentation is delayed. Reported interventions include: lateral canthotomy with cantholysis, bony orbital decompression and treatment of the underlying cause.

Vision loss associated with orbital surgery - a major review

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.

A Historical Perspective of Lateral Canthotomy and Its Adoption as an Emergency Medicine Procedure

BACKGROUND

The treatment of orbital compartment syndrome has a rich history rooted in surgery and emergency medicine. It is a rare but acute and vision-threatening condition that most commonly occurs secondary to facial trauma or as a postoperative complication, and was first recognized in 1950. Surgical techniques and medical management were developed and refined soon afterwards to eventually become the modern-day treatment, lateral canthotomy, and inferior cantholysis.

OBJECTIVE

This article details the history of orbital compartment syndrome and the evolution of its treatment to the present day.

DISCUSSION

Given the time-sensitive nature and acuity of orbital compartment syndrome, lateral canthotomy was adopted by emergency physicians who could perform it more quickly at the bedside.

CONCLUSIONS

Lateral canthotomy is a procedure adopted by emergency physicians from the surgical literature. The history of its adoption is a representative example of how emergency medicine evolves as a field.

Paracanthal "One-Snip" Decompression in a Cadaver Model of Retrobulbar Hemorrhage

PURPOSE

The authors assess the effectiveness of a modified paracanthal or "one-snip" procedure compared with the traditional lateral canthotomy and inferior cantholysis in the reduction of intraocular pressure (IOP) and proptosis in a human cadaveric model of retrobulbar hemorrhage.

METHODS

This study comprised a comparative interventional study in a cadaveric model of retrobulbar hemorrhage. Six orbits of 3 fresh cadavers were included in the study. Baseline measurements of IOP and proptosis were recorded for all 6 orbits before and after simulation of retrobulbar hemorrhage as previously described. Right orbits (n = 3) underwent traditional lateral canthotomy and inferior cantholysis. Left orbits (n = 3) underwent modified paracanthal or "one-snip" procedure. The primary outcome measures were reduction in IOP and proptosis between the 2 techniques.

RESULTS

Following lateral canthotomy and inferior cantholysis of each right orbit, the average IOP dropped to 14 mm Hg (range of 11-18 mm Hg), corresponding to a mean decrease of 32 mm Hg. Following the "one-snip" procedure of each left orbit, the average IOP dropped to 19 mm Hg with a range of 16 to 23 mm Hg, corresponding to a mean decrease of 22 mm Hg. There was no statistically significant difference in IOP reduction (p = 0.36) or proptosis reduction (p = 0.23) between the 2 treatment groups.

CONCLUSIONS

Compared with traditional lateral canthotomy xand inferior cantholysis, the modified paracanthal or "one-snip" procedure is effective for IOP reduction and led to mild improvement of proptosis in a cadaveric model of retrobulbar hemorrhage. The authors hope this study helps improve orbital compartment syndrome outcomes by providing an option that more providers will feel comfortable performing and therefore decreasing time to surgical decompression.

Blindness after facial trauma: epidemiology, incidence and risk factors: a 27-year cohort study of 5708 patients

OBJECTIVES

This was a 27-year study of a cohort of 5708 patients who had sustained maxillofacial fractures. Our purpose was to present the etiology, mechanism of trauma, site, and concomitant injuries that led to visual loss. We hypothesize that fractures caused by high-energy impact of the midface may be associated with blindness. A discussion of the treatment approaches is also included.

STUDY DESIGN

The study included 5708 patients who had sustained a maxillofacial fracture during the years 1985-2012. Patients' records were reviewed for gender, age, fracture site, etiology of trauma, concomitant injuries, method of treatment, length of hospital stay, and cause of blindness. The relationship of the above variables to blindness was investigated.

RESULTS

The incidence of loss of vision was 0.34%. A very strong association between firearm injuries and blindness was observed (P < .001). These patients spent much longer time in hospital (P < .01) and suffered serious concomitant injuries involving the brain.

CONCLUSIONS

Retrobullbar hemorrhage should be treated with lateral canthotomy, whereas in traumatic optic neuropathy, observation seems to be the safest thing to do. In patients with penetrating injuries of the globe, the immediate involvement of an ophthalmic surgeon is of paramount importance.

Retrobulbar hematoma: A systematic review of factors related to outcomes

INTRODUCTION

Retrobulbar hematoma (RBH), a rare but serious condition, can result in permanent vision loss. Although it is a known complication following trauma or facial fracture reduction, sinus surgery, or blepharoplasty, factors related to patient outcomes are not well-defined. A systematic review was performed to determine the relation of patient/treatment factors to outcomes.

METHODS

Articles retrieved from a PubMed search (1989-2017) were reviewed. Demographic information, etiology, symptoms, and final vision outcomes were analyzed using Fisher's exact tests, single and multiple predictor logistic regression.

RESULTS

Of 429 articles identified, 16 were included in the study. 93 cases of retrobulbar hematoma were included. 74% occurred after trauma, while 26% occurred postoperatively. Onset of symptoms occurred after approximately 24 hours. 28% received treatment within 1 hour, 54% within 1-24 hours, and 18% after 24 hours. 51% had complete visual recovery, while 27% had partial recovery, and 22% developed blindness. Older patients and patients who sustained trauma were less likely to have a full recovery (p = 0.029, p = 0.023). Increasing number of symptoms trended towards a prediction of blindness (p = 0.092). Surgical decompression and shorter time to treatment were each highly predictive of full recovery (p = 0.024, p = 0.003) and decreased likelihood of blindness (p = 0.037, p = 0.045); use of steroids was not found to be significant.

DISCUSSION

Retrobulbar hematoma is a diagnostic and therapeutic emergency. Factors associated with improved outcomes include younger age, decreased number of total symptoms, surgical decompression, and shorter time to treatment. If recognized and treated early with surgical decompression, recovery of vision is possible.

Canthal cutdown for emergent treatment of orbital compartment syndrome

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.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Efficacy of transcutaneous transseptal orbital decompression in treating acute retrobulbar hemorrhage and a literature review

Decreasing visual acuity secondary to orbital trauma may be caused by sudden space-occupying or expanding intraorbital lesions, including retrobulbar hemorrhage (RBH), herniation, or swelling. RBH must be diagnosed and treated immediately. This article addresses the efficacy of transcutaneous transseptal orbital decompression in a combination with a systematic review of the literature for a comparison of this method with existing treatment options. For this study the department's database was retrospectively screened for patients with acute RBH who were treated between 2009 and 2011 using the authors' approach. Patients presenting with RBH were classified into RBH classes I to III according to three different clinical and radiological manifestations of acute RBH. The efficacy of transcutaneous transseptal orbital decompression was assessed by postoperative visual acuities. The literature review was performed by using the MEDLINE database. The time period for the study was between 2009 and 2011 during which 10 patients were diagnosed with suspected RBH and 9 were treated with the authors' technique. Visual acuities were reconstituted or maintained in almost 86% of patients who were diagnosed and treated according to the authors approach and who survived initial trauma. It was concluded that transcutaneous transseptal orbital decompression provides an efficient and rapid approach for treating patients with acute RBH. By distinguishing three different manifestations of acute RBH, the authors present a diagnostic tool that may facilitate classification of RBH and determination of treatment options.

Orbital compartment syndrome following aneurysm surgery

Orbital compartment syndrome (OCS) is a rare cause of blindness following intracranial surgery. We report a patient with OCS following intracranial cerebrovascular surgery precipitated by severe straining. OCS occurred due to a rapid increase in intraorbital pressure within the rigid confines of the orbit causing hypoperfusion of critical neural structures, which resulted in visual loss and a complete external ophthalmoplegia. Treatment involved urgent surgical soft tissue decompression of the orbit, corticosteroids and osmotic agents. It is important to consider OCS as a cause of blindness in the neurosurgical postoperative setting as without rapid treatment this condition has a very poor prognosis.

Inferior orbital septum release compared with lateral canthotomy and cantholysis in the management of orbital compartment syndrome

PURPOSE

The purpose of this study is to assess the utility of inferior orbital septum release compared with lateral canthotomy and inferior cantholysis for the treatment of orbital compartment syndrome.

METHOD

An experimental study design using a cadaver model for orbital compartment syndrome was used to compare the efficacy of inferior orbital septum release with lateral canthotomy and inferior cantholysis. Elevated orbital compartment pressures were created in a total of 10 orbits of 5 fresh cadaver heads. Compartment pressure and intraocular pressure were measured before and after inferior orbital septum release and lateral canthotomy/cantholysis. Additionally, orbital compartment pressure was compared with intraocular pressure at various pressures to assess correlation. Statistical analysis was performed on the collected data for efficacy comparison of the 2 procedures.

RESULTS

Both procedures were found significantly to reduce orbital compartment pressure. Lateral canthotomy and cantholysis was found to lower the pressure by an average of 56 mm Hg as compared with inferior septal release, which resulted in an average of 52-mm Hg reduction. Performing lateral canthotomy and cantholysis first, followed by inferior septal release, resulted in a total pressure reduction of 73 mm Hg, whereas reversing the order resulted in a reduction of 77 mm Hg. Both the first and second steps, regardless of the order of procedure, were found to result in a significant pressure reduction (p = 0.009 and 0.004, respectively). Comparison of a series of data points collected during the induction of the experimental compartment syndrome revealed a statistically significant correlation between orbital compartment pressure and intraocular pressure (Spearman correlation of 0.978 and p value <0.001).

DISCUSSION

The study demonstrates that both lateral canthotomy/cantholysis and inferior orbital septum release are equally effective at reducing orbital compartment pressure. Additionally, the data support an additive, synergistic reduction in compartment pressure when the procedures are performed consecutively. The correlation of orbital compartment pressure to intraocular pressure proves that intraocular pressure can be used as a reliable measurement of orbital pressure during acute changes in orbital mass. The results of this study demonstrate that the use of inferior orbital septum release in conjunction with lateral canthotomy and cantholysis is superior to the gold standard of isolated lateral canthotomy and cantholysis. We hope that the implementation of orbital septum release will result in superior visual outcomes.

Radiographic predictors of visual outcome in orbital compartment syndrome

PURPOSE

The goal of this study is to evaluate parameters on orbital CT as predictors of visual outcome in orbital compartment syndrome from retrobulbar hematoma or orbital cellulitis. The study will assess the assertion that certain patients are anatomically predisposed to vision loss in these conditions.

METHODS

A retrospective chart review of consecutive patients with the diagnosis of either orbital cellulitis or orbital hematoma from the clinic of a single provider in an academic practice from 2006 to 2009 was performed. Exclusion criteria included preexisting vision loss, lack of CT scan for analysis, or lack of 1-month follow up for final visual acuity. Measurements of final visual acuity, medial wall length, lateral wall length, distance from the globe to the apex, and a novel measurement of posterior globe tenting (stretch angle) were obtained. Patients were divided into 2 groups: normal visual acuity and vision loss. Statistical analysis was performed to identify significant differences between the 2 groups.

RESULTS

The normal vision group consisted of 11 patients, all with vision of 20/30 or better. The average length of the medial and lateral wall was 43.9 and 41.6 mm, respectively. The average distance from the globe to the apex was 26.3 mm in the uninvolved eye and 30.3 mm in the involved eye, resulting in an average difference of 4.18 mm. The average stretch angle measurement was 28.9° in the uninvolved eye and 28.5° in the involved eye, resulting in an average difference of 0.41°. The vision loss group consisted of 4 patients, all with vision of count fingers or worse. The average length of the medial and lateral wall was 46.9 and 45.7 mm, respectively. The average distance from the globe to the apex was 32.2 mm in the uninvolved eye and 36.7 mm in the involved eye, resulting in an average difference of 4.50 mm. The average stretch angle measurement was 32.3° in the uninvolved eye and 21.1° in the involved eye, resulting in an average difference of 11.2°. The difference in stretch angle between eyes in the vision loss and normal vision groups were found to be highly significant with a p value of less than 0.001. The difference between the 2 orbits for globe to apex is a rough measurement of proptosis and was not statistically different in the 2 groups (p = 0.71), whereas the length from the globe to the apex in the uninvolved eye was statistically different between the vision loss group and normal vision group (p = < 0.001).

CONCLUSIONS

Orbital compartment syndrome is a potentially vision-threatening condition. Minimal objective data are currently available in the literature to guide physicians in making clinical judgments regarding these patients. The results of this study indicate that comparing the novel stretch angle between the patient's 2 eyes and measuring the length from the globe to the orbital apex can help identify patients at risk for poor visual outcome. This study provides objective measurements that can aid ophthalmologists and radiologists in determining the relative threat to vision in patients presenting with orbital compartment syndrome from orbital cellulitis or retrobulbar hematoma. Hopefully, the data can help select patients that may benefit from more aggressive intervention and will ultimately result in superior visual outcomes.

Mechanisms and management of vision loss following orbital and facial trauma

PURPOSE OF REVIEW

To examine the proposed mechanisms of vision-threatening injuries occurring secondary to orbital and facial trauma: traumatic optic neuropathy (TON), retrobulbar haemorrhage (RBH) and penetrating eye injury. To evaluate the evidence supporting different management options for traumatic vision-threatening injury.

RECENT FINDINGS

Despite considerable debate over the roles of surgical decompression and systemic steroid therapy for TON, these interventions have not been proved to be more effective than conservative management and there is limited evidence that the use of steroids may be associated with an adverse outcome. Lateral canthotomy and inferior cantholysis have been proven to be effective treatments for RBH. Orbital exploration and surgical evacuation of haematoma remains a second line intervention. Open globe injuries require immediate primary surgical exploration and repair. Irretrievable devastating globe injuries require either enucleation or evisceration. There is no consensus as to which is the best treatment with recent surveys indicating that enucleation is preferred in the USA and evisceration in the United Kingdom.

SUMMARY

Conservative management is the first line treatment for TON. The evidence strongly supports lateral canthotomy and inferior cantholysis as best treatment for RBH. There is no consensus as to whether enucleation or evisceration is the best treatment for irretrievable devastating globe injury. The choice of management is currently determined by surgeon preference.

A pitfall of decompression for severe exophthalmos: role of the posterior wall of the maxillary sinus-1

This report addresses a pitfall of decompression for severe exophthalmos. In mild cases, removal of the orbital floor is an effective treatment, but in severe cases, the results of this approach are sometimes unsatisfactory, and only decompression is necessary. In these cases, orbital decompression in 3 areas including the medial wall, the lateral wall, and the orbital floor is usually performed. A 5.0-mm mean reduction in exophthalmos is observed, but more reduction is difficult to achieve.We considered the possibility that removal of the posterior wall of the maxillary sinus is critically important to achieving greater recovery. It is proposed that this technique is effective in creating about 10 mm of improvement for severe exophthalmos.

When is a retrobulbar haemorrhage not a retrobulbar haemorrhage?

Retrobulbar haemorrhage (RBH) is a well described condition which is said to be a common cause of acute proptosis following trauma, but the evidence for this is not strong. The authors reviewed 186 publications on the subject, finding 82 cases of RBH related to trauma. This analysis suggests that in over half of the cases described, RBH was never proven conclusively. In the authors' experience RBH is not a common cause of acute proptosis following trauma and other causes need to be considered if patients are to be managed appropriately.

Retrospective analysis of orbital floor fractures--complications, outcome, and review of literature

This retrospective study aimed at investigating indications, surgical approaches, and the materials used for orbital floor reconstructions, as well as the clinical follow-up, particularly with regard to postoperative complications. This study comprised 189 patients who underwent surgery for fractures of the orbital floor between 2003 and 2007. Diagnosis and treatment were based on both physical examination and computed tomography scan of the orbit. Patients were retrospectively analyzed for data, such as mechanism of injury, classification of fracture, and complications. The most common cause of injury was physical assault followed by traffic accidents. Surgery was conducted with a mean delay of 2.9 days after the incident. Mid lower eyelid incision was the most common surgical approach to the orbital floor. For orbital floor reconstruction, polydioxanone sheets (70.5%) were mainly used, followed by Ethisorb Dura (23.3%) and titanium mesh (6.2%). There were 19.0% of patients who showed postoperative complications: 5.8% suffered from persisting motility impairment, 3.7% from enophthalmos, 3.2% from consistent diplopia, 2.6% from ectropion, and 0.5% from orbital infection. Intraorbital hematoma (3.2%) represented the most severe complications, one patient suffered lasting impairment of sight and another one, complete blindness of the affected eye. If postoperative impairment of vision becomes evident, immediate surgical intervention is mandatory. Retrobulbar hematoma is more likely to occur in heavily traumatized patients with comminuted fractures and also in patients taking anticoagulative medication. The subciliary approach to the orbit and repeated operations by the same approach are associated with a higher risk of developing ectropion.

Orbital compartment syndrome: the ophthalmic surgical emergency

Orbital compartment syndrome is an uncommon, ophthalmic surgical emergency characterized by an acute rise in orbital pressure. When intraorbital tension rises, damage to ocular and other intraorbital structures, including irreversible blindness, may occur if not promptly treated. The diagnosis of orbital compartment syndrome is completely clinical and early recognition and emergent orbital decompression (even prior to imaging) is essential in preventing permanent vision loss. Lateral canthotomy and inferior cantholysis remain the mainstays of management. More extensive incision of the orbital septum and orbital bony decompression may be necessary in unresponsive cases. This review discusses the various etiologies and mechanisms resulting in orbital compartment syndrome, clinical features, imaging findings, treatment, and prognosis.

Retrobulbar hematoma as a rare complication after secondary correction of enophthalmos

Retrobulbar hematoma is a rare complication after orbital surgery, with the potentially disastrous consequence of visual impairment and blindness. We report a female patient who was admitted for enophthalmos correction because of the unsatisfactory result of the primary repair of an orbital blowout fracture and who subsequently experienced the complication of retrobulbar hematoma after operation. The initial presentation of the patient was eye pain with vomiting, followed by proptosis and visual impairment. Retrobulbar hematoma was confirmed by computed tomography, and immediate medical and surgical treatments were instituted. The vision of the patient recovered gradually during outpatient follow-up.

Management of severely bleeding ethmoidal arteries

OBJECTIVES

Ethmoidal arteries (EAs) can be responsible for severe bleeding. Clinical features of EA bleeding are rather extensive because it can occur within the nasal cavity or in orbital spaces. Furthermore, surgical management of EA bleeding is challenging.

STUDY DESIGN

Retrospective evaluation.

METHOD OF STUDY

Five clinical patients with severe bleeding from EAs and/or epistaxis refractory to sphenopalatine artery closure were included in this work. Careful anatomic dissection of the orbitoethmoidal region was performed in 3 fresh injected heads.

RESULTS

Ethmoidal artery management is not uniform because it depends on the rapidity and severity of the bleeding and the chambers within which it happens. Trauma-related bleeding usually requires a lateral canthotomy, whereas in intraoperative bleeding, efforts should be made to directly coagulate the bleeding vessel, even within the orbital fat. Spontaneous epistaxis refractory to sphenopalatine artery closure is to be addressed externally, preferably under endoscopic vision.

CONCLUSIONS

Ethmoidal artery management differs according to the clinical situation. Elective surgery is advisable for spontaneous epistaxis, whereas emergency treatment, ranging from intraorbital coagulation of the bleeding vessel to lateral canthotomy (when the patient is in a sight-threatening condition), is necessary when the bleeding occurs within orbital spaces. A treatment management algorithm is useful in cases of severe and refractory EA bleeding.

Acute proptosis in trauma: retrobulbar hemorrhage or orbital compartment syndrome--does it really matter?

PURPOSE

To review the nature and outcomes of acute severe proptosis in patients after craniofacial trauma, over a 6-year period.

PATIENTS AND METHODS

These were identified prospectively. The mechanism of injury, nature of the proptosis, and visual outcomes in each case were reviewed. Review of the literature was undertaken.

RESULTS

In all cases proptosis, was secondary to retrobulbar edema and not hemorrhage.

CONCLUSIONS

Many cases of "retrobulbar hemorrhage" may, in fact, be secondary to edema. This has significant implications when managing the proptosed eye on an emergent basis. Possible reasons for poor outcomes are discussed. A number of unanswered questions arise from this review.

Management of Retrobulbar Hematoma

Background

Retrobulbar hematoma (RH) is a complication that can result from both otolaryngic and ophthalmologic procedures. RH can occur during endoscopic sinus surgery and improper treatment can result in several morbidities, including visual loss. Despite serious consequences, management for RH is not well evaluated. However, lateral canthotomy with cantholysis is generally recommended. The objective of this study is to review the management for RH.

Methods

A retrospective study was performed at our tertiary hospital from 1979 to 2006 for patients with the ICD-9 code for orbital hematoma. The demographic information, comorbidities, presentation, management, follow-up period, and outcomes were evaluated. Data were analyzed.

Results

Twenty-two patients were identified with 13 male patients and an average age of 43 years (range, 11–80 years). The RH was broken into three categories: iatrogenic, six cases; trauma, eight cases; and spontaneous, eight cases. The most common symptom was diplopia followed by orbital pain. The average pretreatment and posttreatment tonometric pressures were 25.3 mm Hg (range, 11–60 mm Hg) and 14.5 mm Hg (range, 10–22 mm Hg), respectively. The average proptosis was 4.3 (range: 0–8) mm. Treatments were observation (13 cases), medical treatment alone (4 cases), and surgical treatment with and without medical treatment (5 cases). Sixty-eight percent of the patient's visual acuity improved with these treatments. Twenty-seven percent had no visual changes from the RH. The average follow-up was 5 years.

Conclusion

Traditionally, lateral canthotomy with cantholysis is recommended for the treatment for RH. However, in certain patients and settings, there may be an acceptable alternative option for the management of RH.

Review of Management Options for a Retrobulbar Hemorrhage

This is a review of the current literature describing the different reported methods of managing a retrobulbar hemorrhage. The pathophysiology of the condition, together with its differing clinical presentations are described in length. Both the surgical and medical management are discussed. The importance of prompt recognition and treatment of the condition is emphasized. The consequences of unnecessary treatment delay are reinforced.

Acute retrobulbar haemorrhage: An ophthalmic emergency

Acute retrobulbar haemorrhage is a rare complication of blunt eye trauma. It can be sight-threatening but is reversible when recognized and treated promptly. We presented a case of acute retrobulbar haemorrhage with profound reduction of vision. Emergency surgical decompression was performed to preserve the vision. Clinical features and management are discussed.