Surgical Approaches to the Orbit: Transpalpebral

The aim of this study is to provide an overview of the safe and effective incisional transpalpebral approaches to the orbit. The location of each approach and pertinent anatomy in each respective area, suggested approach techniques, recommended specialties, reconstruction options, intraoperative neurophysiology, complications, and approach limitations are discussed in detail.

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.

Orbital Compartment Syndrome

Orbital compartment syndrome (OCS) is a true ophthalmological emergency. It develops as a result of an acute rise in intra-orbital pressure, and if not treated immediately, damage to the optic disc and retina will lead to irreversible vision loss. Thus, immediate diagnosis and management are vital to preserve vision. Presented here is a brief summary of OCS in order to call attention to this condition.

Emergency management for orbital compartment syndrome-is decompression mandatory?

Current guidelines for the urgent management of patients with orbital compartment syndrome include immediate lateral canthotomy and cantholysis, followed by surgical decompression. Medical treatment is also advocated to 'buy time' while preparing the patient for theatre. This consists of high-dose steroids, mannitol, and acetazolamide diuretics to reduce swelling and orbital pressure. It is generally recognized that late or delayed intervention is associated with poor outcomes including blindness. With early presentation, given the potential risk to sight, there is generally a low threshold for treating suspected cases. However, whether or not to treat late cases is more controversial, partly because clinicians could face accusations of medical negligence if they do nothing. The case of a patient who sustained an orbital trauma to his only seeing eye, which resulted in acute proptosis and loss of vision, is presented here. He received no treatment at all for what appeared to be an orbital compartment syndrome secondary to retrobulbar haemorrhage, but surprisingly made a full recovery of vision within 48h. In contrast to the current literature in favour of urgent treatment, this case would appear to cast some doubt over the concept of 'always' treating orbital compartment syndrome and our understanding of the condition.

Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome

BACKGROUND

Orbital compartment syndrome is a sight-threatening emergency. Vision may be preserved when timely intervention is performed.

OBJECTIVE

To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration.

DISCUSSION

Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome.

CONCLUSIONS

Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss.