Orbital Compartment Syndrome: Alternative Tools to Perform a Lateral Canthotomy and Cantholysis

Retrobulbar hemorrhage with orbital compartment syndrome: A rare sight-threatening emergency during air medical evacuation

Traumatic retrobulbar hemorrhage may be rapidly progressive, converts to a sight-threatening emergency with potentially devastating complications. Assisted-escape systems in fast jet aircraft can lead to the pilot's facial/orbital injuries at any stage of the ejection sequences, which may result in retrobulbar hemorrhage. Orbital traumas are common and rarely result in retrobulbar hemorrhage and orbital compartment syndrome. However, early diagnosis and urgent out-of-the-hospital lateral canthotomy with cantholysis were recommended to save the patient's vision.

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.

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.

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.