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
This disease is a true emergency in ophthalmology.

Epidemiology

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

Etiology and Pathophysiology

  • Expansion of tissue (Graves thyroid eye disease) or fluid (blood, edema) within a closed space. The orbit is bounded on four sides by bone and anteriorly by the orbital septum.
  • Orbit/globe
    • Decreased visual acuity due to optic nerve and vascular compression
    • Decreased movement of the globe and diplopia due to restriction of extraocular muscles
  • Neurologic
    • Acute onset of pain
  • 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, child labor, or barotrauma.
    • Retrobulbar hemorrhage can also occur following periocular surgery, particularly when the orbital 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. It may also occur with anesthetic injections into the orbit, such as a retrobulbar block, or inadvertently during or endoscopic sinus surgery.
    • 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 medial orbital wall or floor fractures
  • 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 (direct and indirect)
  • 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).
  • Evaluate for and 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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