Bilateral subcutaneous emphysema from pressurized infusion during pars plana vitrectomy: a case report

HW, Albini TA. Orbital Gas after 25-Gauge Pars Plana Vitrectomy with Incorrect Gas Mixture

We present 2 cases of sutureless 25-gauge pars plana vitrectomy and fluid-gas exchange, in which incorrect gas concentrations likely led to elevated intraocular pressures and retrobulbar gas. Combined removal of orbital gas with anterior orbitotomy and pars plana vitrectomy was performed in the first case to address expanding intraocular and retrobulbar gas resulting from a suspected error in gas dilution. Vitreous and orbital gas removal by needling was effective in the second case. In patients with elevated intraocular pressure and orbital gas accumulation after vitrectomy, combined intraocular and orbital decompressions were effective in optimizing clinical outcomes. There is no consensus regarding the best management of orbital gas after vitrectomy. We propose that a multidisciplinary technique should be considered, when available.

PFOh No: Spontaneous Globe Rupture During Injection of Perfluoro-n-Octane (PFO) During Retinal Detachment Repair

The authors describe a case of spontaneous globe rupture during instillation of perfluoro-n-octane (PFO) during retinal surgery. A 71-year-old male with a macular-involving rhegmatogenous retinal detachment underwent pars plana vitrectomy. During instillation of PFO manually on a single-bore cannula by the assisting resident, spontaneous globe rupture occurred superotemporally in an area with no visible underlying structural abnormalities. Factors that led to this complication include the use of single-bore cannula, error in judgment of resistance during PFO injection, and inexperience. This is the first report of this complication without an identifiable structural abnormality predisposing patient to perforation.

Periorbital Subcutaneous Perfluoron Is Well Tolerated Following Intravitreal Surgery

Purpose:

Perfluorocarbon liquids (PFCLs) are well tolerated in intraocular surgery, but chronic exposure can cause inflammation. PFCL leakage into the orbit without significant sequelae has been reported, but PFCL leakage into the preseptal subcutaneous tissues has not been described.

Methods:

A case report is presented.

Results:

A 46-year-old man presented with hand motion vision from a ruptured globe and retained intraocular foreign body. Intraoperatively, the foreign body could not be removed, and PFCL extravasated from the posterior globe rupture. Postoperative imaging revealed hyperdense material in the orbit, lids, and superficial adnexal tissues. The patient tolerated the retained PFCL, and imaging 10 months later demonstrated interval resorption. The patient eventually developed ocular siderosis and underwent transconjunctival orbitotomy with foreign body extraction. Two years following the initial injury, his vision remained stable at 20/40 without further sequelae.

Conclusions:

PFCL is well tolerated in the extraocular space and may resorb with conservative management.

Unilateral Orbital Emphysema Secondary to Vitreoretinal Surgery

PURPOSE

To describe preoperative, intraoperative, and postoperative characteristics, imaging findings, and clinical evolution of patients who developed orbital emphysema after vitreoretinal surgery.

DESIGN

Retrospective, descriptive, observational case series.

PARTICIPANTS

Patients with orbital emphysema after vitreoretinal surgery who were diagnosed and treated between January 2006 and October 2018 at a single ophthalmology referral center.

METHODS

Medical records and orbital computed tomography images were reviewed and analyzed. A minimum follow-up of 3 months was required.

MAIN OUTCOME MEASURES

Final best-corrected visual acuity (BCVA).

RESULTS

This study included 16 patients with a mean age of 47.9 ± 14.7 years, 50% were women, and 25% had a history of previous ocular trauma. A diagnosis of rhegmatogenous retinal detachment was established in 75% of patients. Twenty-five percent of patients underwent pars plana vitrectomy (PPV), 50% underwent encircling scleral buckling plus PPV, 18.8% underwent repeat PPV, and 6.2% underwent scleral buckling plus repeat PPV. Additionally, 62.5% received silicone oil endotamponade. The median time between vitreoretinal surgery and orbital emphysema was 8 days (interquartile range [IQR] 5-15 days). Mean proptosis was 6.7 ± 4.6 mm. Orbital cellulitis was considered as a differential diagnosis in 31.2% of patients, and tomographic evidence of fracture was observed in 25% of patients. Treatment with compressive patching was prescribed for 87.5% of patients, transpalpebral drainage was prescribed for 75% of patients, hyperbaric oxygen therapy was prescribed for 43.8% of patients, and surgical management was prescribed for 31.2% of patients. The comparison between BCVA before vitreoretinal surgery (median, 1.8 logarithm of the minimum angle of resolution [logMAR]; IQR, 1.33-2.3 logMAR) and at the last follow-up (median, 2.3 logMAR; IQR, 1.42-2.8 logMAR) was not statistically significant (P = 0.125, Wilcoxon matched-pairs signed-rank test). No association was found between surgeon experience and lower final BCVA (P = 0.604, Fisher exact test); however, development of ocular hypertension was associated with worse final BCVA (P = 0.0101; relative risk, 7; 95% confidence interval, 1.01-44.63).

CONCLUSIONS

Although orbital emphysema constitutes a very unusual complication of vitreoretinal surgery, it is important to identify this condition promptly and treat patients efficiently to avoid potential vision loss.

Orbital Emphysema: A Case Report and Comprehensive Review of the Literature

PURPOSE

The objective of this study was to report a case of persistent and likely self-induced orbital emphysema (OE) following functional endoscopic sinus surgery with dislodgement of a previously placed orbital floor implant and to review the literature surrounding etiologies, pathophysiology, and management of OE.

METHODS

Case report and review of the literature.

RESULTS AND DISCUSSION

While blunt trauma resulting in disruption of the medial orbital wall is the most common cause of OE, there are an additional 25 underlying etiologies reported in the current literature. Pathophysiology of OE is somewhat dependent on underlying etiology but often involves a 1-way ball valve mechanism such that air may enter the orbit but not exit. When sufficient air enters the orbit, complications secondary to increased intraorbital pressure, including central retinal artery occlusion and compressive optic neuropathy, can occur. Mild cases of OE are typically observed, with most resolving within 7 to 10 days. Moderate cases are often managed by lateral canthotomy and cantholysis with possible needle decompression. Severe cases may require urgent surgical decompression. While the majority of cases of OE are benign and self-limited, there have been 4 reports in the literature documenting significant vision loss.

CONCLUSIONS

Although there is often a history of trauma in patients presenting with OE, many other underlying etiologies have been reported with several cases occurring spontaneously. As such, OE should be included on the differential for a patient presenting with a sudden onset of orbital signs.