Update on orbital decompression as emergency treatment of traumatic blindness

Emergency management of orbital compartment syndrome: Lateral canthotomy and cantholysis case series

BACKGROUND

Orbital compartment syndrome (OCS) is considered a time critical condition that requires urgent surgical decompression to preserve vision. This study aims to evaluate the current clinical criteria for performing a lateral canthotomy and cantholysis (LCC) in the emergency management of suspected traumatic OCS.

METHODS

A retrospective audit of patients with suspected traumatic OCS presenting to an adult major trauma centre between January 1, 2017, and August 1, 2022, was performed.

RESULTS

20 patients with traumatic OCS treated with a LCC were identified. Five patients satisfied the definitive clinical criteria for LCC. The remaining 15 patients received LCC based on secondary clinical findings, or computed tomography (CT) findings suggestive of OCS. 17 patients received non-contrast CT scanning prior to LCC. Of the nine patients noted to regain baseline or close to baseline vision, only one was decompressed within two hours of injury.

CONCLUSION

Despite OCS being a clinical diagnosis, the signs and symptoms associated with OCS are difficult to elicit on presentation. Seeking imaging should not delay time to decompression when clinical diagnostic criteria are present. However, imaging may have a role in determining the need for orbital decompression where the absolute indications for LCC cannot be adequately assessed.

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Acute orbital compartment syndrome due to traumatic hemorrhage: 4-year case series and relevant literature review with emphasis on its management

PURPOSE

Blindness in craniomaxillofacial (CMF) injuries may occur due to acute orbital compartment syndrome (AOCS). Primarily, this article aimed to retrospectively review our 4-year experience in the management of patients diagnosed with AOCS secondary to an orbital hematoma (OH). Furthermore, this paper included up-to-date information regarding the prevalence, diagnosis, management, and prognosis of AOCS.

MATERIALS AND METHODS

We retrospectively screened the medical records of patients who visited our hospital's emergency department (ED) and were examined by an oromaxillofacial surgeon for CMF injuries, between September 1, 2013, and September 31, 2017. The electronic hospital's database was searched to retrieve all cases of CMF trauma admitted or referred to our clinic during this period.

RESULTS

Over a 49-month period, 3,514 patients were managed for CMF injuries in ED; 9 cases (0.26%) were attributed to OCS caused by an OH. This group comprised 5 males and 4 females aged between 32 and 91 years old (mean 65.7, median 70). Seven out of 9 patients were subjected to lateral canthotomy and inferior cantholysis (LCIC), whereas septolysis was applied in 6 of them. Sight was preserved in 3 out of 8 patients (37.5%), since a patient died from a serious intracranial injury. Seven out of 9 patients (77.7%) of the OCS group had a history of hypocoagulable state.

CONCLUSIONS

LCIC, septolysis, and careful dissection within inferotemporal orbital quadrant constitute a reliable approach for emergent orbital decompression. CT scan offers differential diagnosis of acute traumatic proptosis, but it should preferably follow LCIC. In case of OHs without pupillary abnormalities and/or impairment of visual acuity, close monitoring allowing for timely interventions is highly recommended to patients with a history of hypocoagulative status, (uncontrolled or severe) hypertension, head trauma, and decreased level of consciousness or in elderly patients suffering from dementia or without rapid access to follow-up medical care. Clinicians dealing with ED services must maintain high skills in AOCS diagnosis and in LCIC execution.

[Optic nerve decompression-state of the art]

Rarely, but often with serious consequences for the patient, the optic nerve is affected during the course of head injuries. Traumatic optic nerve compression is always an emergency situation, which is why time is of the essence for both diagnosis and treatment. Precise knowledge of this accident sequelae but also of the resulting conditions, especially in terms of traumatic optic neuropathy, is indispensable for adequate patient care. The aim of this paper is to provide an overview of this clinical picture, particularly with regard to etiology, diagnosis, and treatment options, and to discuss this in the context of the current literature.

Canine Retrobulbar Cellulitis and Abscessation in the Southeastern United States: A review of case management, diagnostic imaging, bacterial isolates, and susceptibility patterns

OBJECTIVE

To describe common bacterial organisms cultured from retrobulbar cellulitis and abscess lesions, in vitro susceptibility patterns, common diagnostic techniques utilized, etiologies encountered, and prevalence of blindness.

ANIMALS STUDIED

Thirty-eight dogs diagnosed with retrobulbar cellulitis or abscessation from 2007 to 2017.

PROCEDURE

For cases of orbital cellulitis or abscess, signalment, orbital imaging, cytology, histopathology, bacterial culture and susceptibility testing, presence of vision at the initial examination and resolution, and presumed cellulitis/abscess etiology were recorded.

RESULTS

Most cases were medically (78.9%) versus surgically managed (18.4%). Most common form of orbital imaging was computed tomography (48.5%) followed by ocular ultrasound (18.2%). Fifteen of eighteen cultures (83.3%) showed growth of aerobic bacterial organisms, anaerobic bacterial organisms, or both. Most common aerobic bacteria were gram-negative bacilli (40.0%) followed by Corynebacterium sp. (26.7%) and α-hemolytic Streptococci sp. (26.7%) but Micrococcus and Bacillus spp. were also identified. Most common anaerobic bacteria were gram-negative bacilli (40.0%). Antibiotics with highest susceptibility patterns included gentamicin, followed equally by amoxicillin/clavulanic acid, cephalothin, chloramphenicol, and imipenem. No bacteria were susceptible to cefovecin. Six cases presented with vision loss due to retrobulbar disease (15.8%). Idiopathic (50%) disease and tooth root abscessation (23.7%) were most commonly diagnosed cause of orbital disease.

CONCLUSION

Retrobulbar cellulitis/abscess is a serious and vision-threatening process, which can be effectively managed by broad-spectrum antibiotics such as gentamicin or amoxicillin/clavulanic acid, but not cefovecin. This study identified three organisms that have not been previously reported to be associated with orbital cellulitis (Corynebacterium sp., Bacillus sp. and Micrococcus sp.).

An Easily Assembled, Low-Cost Model for Lateral Canthotomy Education

BACKGROUND

Lateral canthotomy is a vision-saving procedure. However, the low incidence of orbital compartment syndrome and the expense of simulators to practice this procedure can lead to low confidence and delays in the performance of the procedure by emergency physicians.

DISCUSSION

We used a simple, inexpensive, easily assembled eye model for lateral canthotomy education at a residency program and a national conference obtaining feedback from simulation participants. Residents rated procedure laboratories that included the lateral canthotomy model as 4.9 to 5 (on a 5-point Likert scale, with 5 being the best score). National conference participants rated the model a 9 as a useful training model for practitioners on a 10-point Likert scale.

CONCLUSION

This simple task trainer is practical, inexpensive, quickly assembled, and useful as a tool for practicing emergency medicine providers.

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.

Retrobulbar haematoma in the era of anticoagulants

AIM

The present retrospective study aimed to evaluate the frequency and distribution of retrobulbar haematoma (RBH) among 26 patients (12 male/14 female) who had suffered maxillofacial trauma/surgery, with special focus on anticoagulants, causes of accidents, treatment, and outcome.

METHODS

Patient ages ranged from 8 to 94 years, with a mean of 65 years. Among all patients, 43% had received anticoagulant therapy at admission; 92.3% had a previous history of maxillofacial trauma.

RESULTS

The most frequent cause of RBH were falls (65.4%), and three patients experienced RBH postoperatively after treatment using polydioxanone foil. Postoperatively (after RBH relief), 33.3% of the patients reported persistent complete visual loss; of these patients, 29% had received anticoagulation therapy, and the oral anticoagulant intake was not documented in further 29% of the patients.

CONCLUSION

Awareness of this pathologic process is crucial for preventing permanent loss of vision via early diagnosis and adequate therapy. With increasing age, patients are more likely to receive an anticoagulant, which leads to a higher risk of RBH. Because falling was the most frequent cause of RBH in our patient population and increases in frequency with increasing age, fall prevention is crucial.

Orbital Decompression for Treatment of Acute Visual Loss After Facial Trauma

Injury to the orbital region represents a significant proportion of emergency department attendances and it is a common injury in patients with multisystem trauma. To date, trauma remains a leading cause of monocular blindness.Traumatic optic neuropathy may be caused by direct trauma to the optic nerve and from compression caused by foreign bodies and bone fragments. Indirect trauma can lead to visual loss from transmitted force to the optic canal by blunt facial trauma without associated fractures. Occasionally traumatic optic neuropathy is due to reversible changes, such as edema or contusion.High-dose intravenous steroids and surgical decompression of the optic canal have been advocated for the management of acute traumatic optic neuropathy, but the efficacy and safety of these treatments have been questioned.The authors present 3 patients with traumatic optic nerve injury, 1 due to a gunshot wound to the face and 2 caused by blunt facial trauma, where fragments of bone intrude into the orbit leading to compression of its content. These injuries where successfully treated with both preoperative intravenous steroids followed by acute surgical decompression of the orbit with return of visual function.

Orbital compartment syndrome resulting in unilateral blindness in two dogs

Orbital compartment syndrome (OCS) is described in humans as an acute rise in intraorbital pressure following a severe and rapidly evolving orbital affection. It includes orbital oedema, haemorrhage or infection causing a marked reduction in local blood perfusion, and severely affecting the orbital neurovascular structures. If not promptly recognised and treated, it results in irreversible blindness. It is one of the rare ophthalmic surgical emergencies, requiring lateral canthotomy and cantholysis. This case report describes two canine cases of complex orbital, periorbital and facial abscesses resulting in OCS and permanent unilateral blindness diagnosed by ultrasonography, computed tomography and electroretinography.

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.

A low fidelity eye model for lateral canthotomy training

We introduce a low-fidelity, low-cost, reusable training model for the lateral canthotomy procedure. We believe that this trainer has the potential to improve clinicians' knowledge and skill of the procedure, especially when cost or access to higher-fidelity trainers is prohibitive.

Impact of antithrombotic treatment in orbital haematoma

INTRODUCTION

Orbital haematomas threaten the visual prognosis, but no treatment guidelines have been proposed. Antithrombotics could affect their prognosis and treatment. This study aimed to evaluate the effect of antithrombotics in the management of orbital haematomas and to suggest a standardised protocol.

MATERIAL AND METHODS

We conducted a retrospective study by sending a standardised questionnaire to 20 French maxillofacial surgery university departments to collect all the cases of orbital haematoma.

RESULTS

Twenty-five cases from 10 centres were collected, including five patients treated with anticoagulant and one patient treated with dual antiplatelet. Antithrombotics increased the risk of amaurosis and ocular disorders significantly. Surgery was performed for 66.7% of patients treated with antithrombotic and for 89.5% of other patients. Surgical delay was longer in patients treated with antithrombotic. Surgical drainage was used in most of the cases, whereas canthotomy with inferior cantholysis was the least-used technique.

CONCLUSION

Antithrombotics appear to worsen the functional prognosis of orbital haematomas. A surgical management of orbital haematoma in patients treated with antithrombotics is not contraindicated. Surgical delay must be shortened as much as possible. A lateral canthotomy with inferior cantholysis seems to be an appropriate solution.

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.

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.

The "tight orbit": Incidence and management of the orbital compartment syndrome

PURPOSE

The orbital compartment syndrome (OCS) constitutes a severe emergency, requiring immediate clinical diagnosis and surgical decompression. The key symptom is progressive visual impairment caused by an increase in intraorbital pressure, impairing the perfusion of relevant neurovascular and neurosensory structures. Intraorbital bleeding due to trauma and surgical intervention is known to be the main etiological factor.

MATERIAL AND METHODS

A retrospective analysis of all patients affected by an OCS between January 1, 2012, and May 31, 2015, was performed. Patients' records were reviewed with regard to etiology, initial ophthalmologic status, fracture pattern, concomitant medication, surgical management, and postoperative outcome. The incidence of OCS was calculated based on the total number of craniomaxillofacial (CMF) emergencies.

RESULTS

Within 3.5 years, a total of 18,093 CMF emergencies were registered. In 16 patients, an OCS was documented, corresponding to an incidence of 0.088%. The mean patient age was 67.31 ± 23.86 years, ranging from 22 to 102 years. The etiology varied, but trauma with subsequent intraorbital bleeding was the main cause. The use of anticoagulative medication was documented in 50% of the cases. In 14 patients, immediate surgical orbital decompression was performed: in 10 patients, vision could be preserved; in three patients, blindness resulted; and one patient was lost to follow-up. Two patients were managed without surgery.

CONCLUSION

With regard to the total number of CMF emergencies, OCS is a rare condition. Early clinical diagnosis and surgical decompression are required to prevent permanent vision impairment. Anticoagulative medication must be considered as a predisposing factor for an orbital compartment syndrome in patients affected by periorbital trauma.