Images in Emergency Medicine

Article Outline

• Diagnosis
  • Acute orbital compartment syndrome as a result of retrobulbar hematoma
• References
• Copyright

An intoxicated 23-year-old man was brought to the emergency department after having been assaulted. He had been punched in the left eye and complained of eye pain. His examination revealed the following findings in the left eye: a reduced visual acuity (oculus dexter 20/30, oculus sinister 20/400), ecchymosis, proptosis, a tense orbit, voluminous subconjunctival hemorrhage, and an afferent pupil defect. The cornea was clear and the anterior chamber was unremarkable. The optic nerve and retina were clearly visible and unremarkable.

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Diagnosis 

Acute orbital compartment syndrome as a result of retrobulbar hematoma 

Computed tomography scan (Figure 1) revealed an intraorbital hematoma adjacent to the superior rectus muscle of the left eye (arrows). The patient underwent an emergency left orbital decompression by lateral canthotomy with inferior cantholysis, after which the hematoma was seen to protrude from underneath the upper eyelid (Figure 2). The patient had an immediate recovery of visual acuity oculus sinister to 20/40, with reduction of intraocular pressure and resolution of the afferent pupil defect. Vision further improved until normal in the ICU.

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• Figure 1. 

  Computed tomography scan of the orbit.

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• Figure 2. 

  Left-eye lateral canthotomy and cantholysis. Used with permission of Kohei Hasegawa, MD, the Department of Emergency Medicine, United States Naval Hospital Okinawa, Okinawa, Japan.

Acute retrobulbar hemorrhage with orbital compartment syndrome is an ophthalmologic emergency whose prompt diagnosis and treatment are essential to prevent permanent vision loss. This rare complication can follow blunt eye trauma, eyelid surgery, and retrobulbar anesthesia. Increased pressure in the retrobulbar location arises from a retrobulbar hematoma (a compartment syndrome), causing decreased perfusion of the optic nerve. Without decompression, irreversible vision loss will occur in 90 to 120 minutes. The emergency procedure of choice for orbital compartment syndrome is lateral canthotomy with cantholysis. It is a safe and effective procedure that decreases intraorbital pressure by increasing orbital volume and should lead to immediate reversal of vision loss. With blunt periorbital trauma, the following clinical findings mandate immediate intervention:

Other measures that can be used to increase the perfusion pressure of the optic nerve are topical antiglaucoma medications, oral acetazolamide, and intravenous hyperosmotic agents.¹ Once the pressure is relieved acutely, the eyelid deformity can be easily repaired at a later time.

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References 

1. Kunimoto DY, Kunal DK, Makar MS. The Wills Eye Manual. In: Philadelphia, PA: Lippincott, Williams, & Wilkins; 2004;p. 29–31
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