Orbital Compartment Syndrome

    • CE credits 2 hours
    • COPE code 51826-AS / 115049
    • Available until Dec 19, 2019

Introduction

Learning Objectives

  • To review the pathophysiology, causes, and diagnosis of orbital compartment syndrome
  • To review medical and surgical techniques for the treatment of orbital compartment syndrome
  • To review the concept of level of evidence (epidemiology module)

Case

A 42-year-old male patient of yours presents to your clinic on an urgent basis for decreasing vision and “protrusion” of his left eye. The patient says that over the last 48-72 hours he has noticed increasing proptosis, decreased vision, and pain of his left eye. Yesterday he had diplopia, although no longer has it today. He has especially noticed vision decreasing the last several hours. He feels unwell with fever, chills, and rigors. He has a long history of sinusitis and also has poorly controlled diabetes mellitus.

External examination of the patient is shown below. The left periorbital area is warm, tense, and severely swollen. There is conjunctival chemosis and obvious left sided proptosis. Visual acuity is counting fingers (previous exam 20/20) with a relative afferent pupillary defect. Extraocular movements are impaired in all directions of gaze. Intraocular pressure is measured at 65.

Quick Question

What is the first step in management of this patient?

  • One week referral to an ophthalmologist

    The patient has orbital compartment syndrome and requires immediate treatment to relieve orbital pressure and prevent further irreversible vision loss. If an Ophthalmologist is available, they should be consulted immediately.

  • You would have the family doctor initiate a course of oral antibiotics

    While the patient likely has orbital cellulitis, the most worrisome concern is that the patient has orbital compartment syndrome. The latter takes precedence and requires steps to decrease orbital pressure.

  • The patient should be referred emergently for a lateral canthotomy and cantholysis
    CORRECT
  • The patient should be referred semi-urgently for intravenous acetazolamide and mannitol

    Medications such as acetazolamide may have a place in treatment of orbital compartment syndrome, but as an adjunctive rather than primary role.

Introduction

Orbital compartment syndrome is an ocular emergency characterized by an acute rise in orbital pressure that decreases perfusion to the optic nerve and retina.1 It may be the end result of a variety of conditions including retrobulbar hemorrhage, orbital cellulitis, and others. Although rare, it is a condition that all eye care professionals must be knowledgeable of as it is one of few eye-related conditions requiring emergent management (i.e. minutes matter).

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