Emergency management for orbital compartment syndrome—is decompression mandatory?

Abstract

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 48 h. 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.

Acute proptosis following trauma is a well-recognized phenomenon usually seen following high energy impacts around the orbit. In the context of trauma, acute proptosis is commonly due to either oedema (often referred to as orbital compartment syndrome, OCS) or blood (retrobulbar haemorrhage).

The management of retrobulbar haemorrhage has been well described, and consists of three main elements : (1) medical treatment with steroids, mannitol, and diuretics, (2) lateral canthotomy and cantholysis, and (3) surgical decompression. The incidence of retrobulbar haemorrhage, as reported in a recent study, appears to be in the region of 3–4%, with an incidence of permanent blindness of 0.14%.

Current opinion supports the notion that the earlier the treatment is undertaken, the better the prognosis. If diagnosis and treatment are undertaken quickly, then outcomes can be good, with complete recovery of vision. Lateral canthotomy with lateral cantholysis, followed by surgical decompression within 2 h of the injury appears to be the most effective treatment in clinically diagnosed OCS. It is also generally accepted that late presentation with severe or total loss of vision carries a very poor prognosis. A case that appears to challenge this understanding is presented herein.

Case report

A 76-year-old gentleman presented to the accident and emergency department following a fall at home that day. He was initially assessed by the emergency department doctors to rule out any head injury, cardiac event, or stroke as the cause of his fall. He was subsequently referred to the maxillofacial team 4 h after attending the emergency department (approximately 5 h after his injury) after one of the doctors noticed that he was blind in his left eye and that his computed tomography (CT) head scan showed a bleed into the left orbit with an associated proptosis.

The patient’s medical history was complicated and included pre-existing and longstanding blindness in the opposite eye, chronic renal failure requiring twice-weekly renal dialysis, anuria related to his poor renal function, and a history of peptic ulcer.

Following referral he was urgently seen and examined by both authors ( Fig. 1 ). The following features were noted on repeated examinations: acute tense and painful proptosis of the left eye, with a ‘stony hard’ feel to the globe; fixed dilated left pupil; blindness in the left eye, with no perception of light; ophthalmoplegia; pre-existing blindness in the right eye. These clinical features were noted by at least five members of medical staff.

Fig. 1
Clinical photograph demonstrating proptosis and periorbital swelling (images courtesy of Mr Ramachandra Madattigowda).

As part of his initial work-up in the emergency department, a CT scan was performed. This showed the presence of both blood and oedema behind the eye, confirming the clinical suspicion of OCS with some retrobulbar haemorrhage ( Fig. 2 ).

Fig. 2
Orbital compartment syndrome. Axial and sagittal CT imaging confirming true proptosis; the left optic nerve is on stretch, with the so-called ‘balloon on a string’ appearance. The red arrow demonstrates an orbital bleed.

A funduscopic examination was not performed because there was sufficient evidence to confirm the diagnosis of retrobulbar haemorrhage. The case was discussed with ophthalmology doctor colleagues who recommended that management be performed by the maxillofacial team and who confirmed that the patient did not require any further assessment from them.

In view of the patient’s age, comorbidities, and total loss of vision, together with the time delay, it was felt that the risks of orbital exploration and evacuation of haematoma/decompression of oedema under general anaesthetic outweighed the small likelihood of visual recovery. Unfortunately, the history of anuria requiring dialysis precluded the use of diuretics. The only treatment options that remained were high-dose steroids (dexamethasone at 3 mg/kg) and immediate lateral canthotomy and cantholysis. Given the past medical history of peptic ulcer disease, significant gastric bleeding was a serious concern. After consultation with the patient and his wife, they decided that they would not want to take that risk and therefore steroids were not given.

All of these options were discussed in great detail with the patient and his wife so that they could make an informed decision as to what should be done, but they chose to decline all forms of treatment and were willing to accept that he would now be totally blind. The patient was then admitted to the care of the medical team for further evaluation of the cause of his fall. It was therefore planned to review the patient regularly during his time as an inpatient.

The next day the patient was reviewed on the ward round and was unexpectedly found to have light perception in his left eye. The day after, he was sitting in a chair eating his breakfast unaided and had return of full vision to his left eye assessed by Snellen chart. The proptosis and ophthalmoplegia were still clearly evident, but over the next few days began to show signs of resolving. On review at 6 months, he continued to have full visual recovery with no relapse.

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Dec 15, 2017 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Emergency management for orbital compartment syndrome—is decompression mandatory?
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