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Orbital Compartment Syndrome

Orbital Compartment Syndrome is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Elevated intraorbital pressure, compromising blood flow to the optic nerve and globe
  • Subacute versus acute subtypes
    • Subacute orbital compartment syndrome (OCS) may be due to enlarging tumors or Graves disease (1).
    • Acute OCS may be due to hematoma or subcutaneous emphysema:
      • Permanent damage can ensue in 60 to 100 minutes of onset (2).
      • Requires immediate relief of pressure to avoid permanent blindness

ALERT
One of the few true emergencies in ophthalmology

Epidemiology

Incidence
  • Incidence after facial trauma is ~2–3%.
  • Incidence with blepharoplasty is 0.055% (3).
  • Incidence with craniomaxillofacial emergencies is 0.088%.

Etiology and Pathophysiology

  • Eye
    • Decreased visual acuity due to optic nerve and vascular compression
    • Decreased visual movements of the globe and diplopia due to restriction of extraocular muscles
  • Neurologic
    • Acute onset of pain
  • Expansion of tissue (Graves) or fluid (blood, edema) within a closed space. The orbit is bounded on four sides by bone and anteriorly by the orbital septum, which is fused to the orbital rim and lids.
  • Orbital hemorrhage, with accumulation of blood (3)
    • Posttraumatic and postsurgical retrobulbar hemorrhage are the most common causes overall.
    • Precipitating trauma does not have to be severe enough to cause fracture and can be “indirect,” from uncontrolled sneezing, coughing, Valsalva maneuver, labor, or barotraumas.
    • Retrobulbar hemorrhage can also occur following eyelid/periocular surgery, particularly when the septum is breached during preaponeurotic fat excision, when there is traction on periorbital fat or when the effects of epinephrine have worn off, resulting in reflex vasodilation; may also occur with anesthetic injections into the orbit, such as a retrobulbar block
    • Nonophthalmic surgeries can also be responsible (sinus, facial trauma surgery, orthognathic, neurosurgery).
    • Hematologic disorders may be predisposing.
    • Up to 50% of cases occur in the setting of anticoagulant use.
  • Proptosis (e.g., as in Graves disease), with limitation of forward movement by the eyelids
  • Eyelid burns
  • Nose blowing, which can force air into the orbit, in patients with orbital fracture
  • Orbital edema
    • Inappropriate packing during orbital/sinus surgery
    • Excess pressure on eye during periocular surgery
    • Intracranial surgery increases risk.
  • Intraorbital abscess
  • Orbital cellulitis (infectious or chemical)
  • Rapid growth of a neoplasm
  • Prolonged hypoxemia with capillary leak
  • Intraorbital foreign body
  • Excessive fluid resuscitation after burn injury or blood loss (2)

Risk Factors

  • Trauma (including trauma that does not result in facial fracture, indirect trauma)
  • Coagulopathy (including blood dyscrasias, hepatitis)
  • Use of NSAIDs, antiplatelet medications, anticoagulants, thrombolytics, certain herbal medications, and corticosteroids
  • Graves disease (subacute compartment syndrome)
  • Excessive IV fluids or blood products (2)

General Prevention

  • Encourage patient to avoid facial trauma (e.g., bar fights, car accidents, contact sports), and wear protective head gear when possible (e.g., helmets).
  • Treat coagulopathies.
  • Limit patient’s use of NSAIDs, antiplatelet and anticoagulants, thrombolytics, certain herbal medications, and corticosteroids, especially before any craniomaxillofacial surgery.
  • Monitor Graves ophthalmopathy closely.
  • Avoid excess IV fluids, when possible.
  • Ensure close contact of patient with orbital surgeon or emergency ophthalmologic care.
  • Counsel patient to avoid blowing nose after facial trauma, particularly orbital fracture (1).

Commonly Associated Conditions

  • Graves disease
  • Coagulopathies
  • Intraorbital abscesses
  • Orbital cellulitis
  • Surgery with significant blood loss (requiring IV fluids or blood products) (2)

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Citation

Stephens, Mark B., et al., editors. "Orbital Compartment Syndrome." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816333/all/Orbital_Compartment_Syndrome.
Orbital Compartment Syndrome. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816333/all/Orbital_Compartment_Syndrome. Accessed April 26, 2019.
Orbital Compartment Syndrome. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816333/all/Orbital_Compartment_Syndrome
Orbital Compartment Syndrome [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 26]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816333/all/Orbital_Compartment_Syndrome.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Orbital Compartment Syndrome ID - 816333 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816333/all/Orbital_Compartment_Syndrome PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -