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 (eg, ≥40 mmHg), but this should only be checked if no findings to suggest an open globe injury^Δ

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 is ideally performed by an ophthalmologist or other experienced surgeon whenever possible. If neither is readily available, then it can be performed by the emergency physician. Refer to UpToDate content on lateral canthotomy and inferior cantholysis for a detailed description of this procedure.

Δ The pressure of 40 mmHg is not a strict cutoff and needs to be interpreted in the context of how the eye is functioning. If at any pressure ≥30 mmHg the eye can see no better than hand motion or light perception or has an afferent pupillary defect, then the eye is at risk for permanent damage. On the other hand, if the eye is functioning well, it may be able to tolerate a pressure of 40 to 50 mmHg for several hours.

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Orbital compartment syndrome: Rapid overview of emergency management