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Orbital compartment syndrome: Rapid overview of emergency management

Orbital compartment syndrome: Rapid overview of emergency management
History
  • Orbital or periorbital trauma with acute onset of decreased vision
  • Eye pain
Physical examination
  • Major findings:
  • Decreased visual acuity*
  • Afferent pupillary defect
  • Proptosis
  • Diffuse subconjunctival hemorrhage
  • Tight ("rock hard") eyelids and decreased retropulsion (cannot push the eye deeper into the orbit or a "tight orbit")
  • Other possible findings:
  • Periorbital bruising
  • Chemosis
  • Conjunctival venous congestion
  • Decreased extraocular movement
  • Optic disk swelling and vascular edema on funduscopy
  • Increased ocular pressure
  • Abnormal color vision
Treatment
  • Emergency lateral canthotomy and inferior cantholysis for orbital decompression
  • After decompression, further management is directed by an ophthalmologist and includes:
  • Elevate the head of the bed (30 to 45°)
  • Ensure adequate pain control (eg, morphine or fentanyl)
  • Treat increased intraocular pressure (refer to UpToDate content on angle-closure glaucoma)
  • Treat elevated blood pressure that persists despite adequate pain control
  • Correct any coagulopathy; reverse or modify anticoagulation therapy as needed if risk of medical complications from discontinuation is low
  • Avoid sudden increased intraorbital pressure; interventions may include:
    • Antiemetic therapy (eg, ondansetron)
    • Cough suppressants, as needed
    • Stool softeners to decrease straining with bowel movement
  • Perform advanced imaging of the orbital region:
    • Non-contrast orbital CT with 1- to 2-mm cuts in the axial or coronal plane
      or
    • MRI (if no contraindications)
  • Consult surgical specialists for definitive management (eg, ophthalmologist, oromaxillofacial surgeon, plastic surgeon, and/or otolaryngologist)

CT: computed tomography; MRI: magnetic resonance imaging.

* Decreased visual acuity (20/40 [6/12] or worse) in patients with prior normal vision or, for patients with abnormal vision, a decrease of more than one line on the Snellen visual chart from baseline indicates a serious loss of vision.

¶ Surgical treatment of orbital compartment syndrome should not be delayed by diagnostic imaging and should be performed by an ophthalmologist or other experienced surgeon whenever possible. If neither is available, then it should be performed by the physician most experienced with managing eye injuries. Refer to UpToDate content on lateral canthotomy and inferior cantholysis for a detailed description of this procedure.
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