Orbital Compartment Syndrome Leading to Visual Loss following Orbital Floor Reconstruction

Orbital floor fractures-a comparison between CT images and findings at surgery

PURPOSE

The present study aims to investigate how well CT images correlate to surgical findings in orbital floor fractures and to the presence of diplopia.

METHODS

In this cross-sectional study, 27 consecutive patients already selected for surgery due to an orbital floor fracture underwent a routine CT scan (axial, coronal, sagittal). An ophthalmologist established any presence of diplopia. Extent of fracture/injury seen on CT was compared to that discovered during surgery.

RESULTS

In the surgeons´ opinions CT-images were in concordance with surgical findings in 71% of the cases. Agreement for pure blow out fractures was high (92%). Tetrapod fractures as a cause of an orbital floor fracture was only identified as such by surgeons in three of 11 cases, all subjected to orbital exploration, not only a closed reduction. Diplopia showed a significant correlation to rounding of the inferior rectus muscle at coronal CT. "Rounding" significantly correlated with the presence of a floor defect, to herniation of soft tissues and to the volume of displaced tissue.

CONCLUSIONS

The results imply that the joint professional interaction between neuroradiology and surgery is important and would benefit from the use of an easy and well-defined classification system of orbital floor fractures. In Sweden a national record to collect data on all zygomaticomaxillary complex fractures assessed is to be started aiming at making general statements possible by time.

Incidence and management of retrobulbar hemorrhage after blowout fracture repair

BACKGROUND

Retrobulbar hemorrhage (RBH) is a rare complication after orbital surgery but associated with ocular complications including blindness. The aim of this study was to identify clinical characteristics of patients with RBH requiring emergent orbital decompression after blowout fracture repair.

METHOD

A retrospective review of 426 blowout fracture patients at a tertiary oculoplastic clinic provided data regarding demographics, physical examination findings, and computed tomography (CT) images. Extraocular motility had been recorded in patient charts on a scale from 0 to - 4. Patients requiring emergent orbital decompression due to RBH after surgery (RBH group) were compared with those who did not (Control group), using the Mann-Whitney U-test. Incidences of RBH according to primary or secondary surgery were also investigated, using Fisher's exact test.

RESULT

Five (1.2%) of the 426 patients who underwent blowout fracture repair developed RBH requiring emergent intervention. All RBH patients fully recovered after the decompression procedure or conservative treatment. Number of days to surgery was significantly longer in the RBH group (97.0 ± 80.1) than in the Control group (29.0 ± 253.0) (p = 0.05). Preoperative enophthalmos was also significantly greater in the RBH group (RBH vs. Control group, 3.6 ± 1.7 mm versus 1.2 ± 1.3 mm (p = 0.003)). The incidence of RBH was significantly higher in patients that underwent secondary surgery (odds ratio = 92.9 [95% confidence interval, 11.16-773.23], p = 0.001).

CONCLUSIONS

Surgeons should pay more attention to hemostasis and postoperative care in patients with a large preoperative enophthalmic eye, when time from injury to surgery is long and in revision cases. When RBH occurs, time to intervention and surgical decompression is critical for visual recovery and preventing blindness.

TRIAL REGISTRATION

The institutional review board of the Yeungnam University Medical Center approved this study ( YUMC 2018-11-010 ), which was conducted in accord with the Declaration of Helsinki.

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.

Analysis of complications following multidisciplinary functional intervention in paediatric craniomaxillofacial deformities

Paediatric craniomaxillofacial (CMF) surgery requires a multidisciplinary team approach to ensure the optimal and holistic management of children with craniofacial deformities. The aim of this retrospective study was to analyse the complications following functional interventions among 34 CMF deformity patients in a single multidisciplinary craniofacial centre. Electronic data including patient demographic characteristics and clinical entry were analysed. Inclusion criteria were all paediatric patients with CMF deformities who underwent various functional interventions. A total of 64 interventions (48 intermediate and 16 definitive) were conducted. Based on the Sharma classification of complications, 20.3% were type I, 4.7% were type II, 1.6% were type III, and 4.7% were type IV . Most complications were type I, which included local infection (3.1%) and premature opening of tarsorrhaphy (3.1%). More serious complications (types III and IV) included temporary visual loss (1.6%) and intraoperative haemorrhage (1.6%). Although a low complication rate was observed in intermediate interventions, a higher complication rate was observed in more complex definitive interventions such as monobloc distraction osteogenesis. Although most complications were manageable, effective prevention remains mandatory, as serious complications may lead to permanent damage and mortality. This analysis highlights the importance of a multidisciplinary team approach to optimize the outcomes in CMF patient management.

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.

Incidence, Risk Factors, and Management of Blindness after Orbital Surgery

PURPOSE

Severe vision loss is a risk of orbital surgery which physicians should counsel patients about, but the overall risk rate is unknown. This research was conducted to determine the risk of severe vision loss related to orbital surgery.

DESIGN

Retrospective review.

PARTICIPANTS

Patients who underwent orbital surgery at either of 2 academic medical centers between January 1994 and December 2014.

METHODS

A billing database search was conducted to identify all patients who had orbital surgery during the study period, cross-checked against diagnostic codes related to vision loss. Charts were screened to determine baseline demographic and medical history, surgical procedure, intraoperative and perioperative management, and visual acuity. Patients with preoperative visual acuity ≥20/200 that worsened ≤20/400 after orbital surgery were included for detailed review. Statistical analysis was conducted to identify factors posing particular risk or benefit to visual outcome in these patients.

MAIN OUTCOME MEASURES

Visual acuity after orbital surgery.

RESULTS

A total of 1665 patients underwent orbital surgery during the inclusion period, with 14 patients sustaining severe vision loss ranging from counting fingers at 1 foot to no light perception (overall risk, 0.84%). The causes of vision loss included retrobulbar hemorrhage, malpositioned implant, optic nerve ischemia, or direct optic nerve insult. When stratified by surgical approach, the risk of a blinding surgical complication was significantly higher for patients undergoing orbital floor repair in the setting of multiple facial fractures (subgroup risk, 6.45%), bony decompression of the optic canal (subgroup risk, 15.6%), or intracranial approach to the orbital roof (subgroup risk, 18.2%). Seven of 8 patients with a potentially reversible cause of postoperative vision loss underwent urgent repeat surgery, and 2 regained substantial vision (20/20 and 20/25). Administration of intravenous corticosteroids had no significant effect on visual acuity outcome.

CONCLUSIONS

The overall risk of severe vision loss after orbital surgery is 0.84%. The subgroup risk is higher in patients undergoing facial polytrauma repair, optic canal decompression, or orbital apex surgery from an intracranial approach. Close postoperative monitoring and urgent assessment and management of acute vision loss may improve visual outcome in some patients.