eMedicine Specialties > Emergency Medicine > Ophthalmology

Acute Orbital Compartment Syndrome: Treatment & Medication

Author: David A Peak, MD, Assistant Residency Director of Harvard Affiliated Emergency Medicine Residency, Attending Physician, Massachusetts General Hospital; Consulting Staff, Department of Hyperbaric Medicine, Massachusetts Eye and Ear Infirmary
Contributor Information and Disclosures

Updated: Nov 3, 2009

Treatment

Prehospital Care

• Trauma evaluation should proceed as per standards for patients with head trauma/multiple trauma, with assessment for life-threatening injuries and stabilization for transport.
• Field treatment of pain, agitation, and emesis may be appropriate to avoid further increase in IOP. If intubation is necessary, pretreat with agents that protect intracranial/intraocular pressures.
• Use protective eye shields during transport when the differential diagnosis includes penetrating eye injury or scleral rupture.
• Check visual acuity early and often. Loss of visual acuity, in contradiction to other symptoms and signs, requires immediate emergent attempts at orbital decompression.

Emergency Department Care

• Assessment for concomitant life-threatening injuries takes priority over all other considerations.
• Immediately employ medical therapy. Osmotic agents and carbonic anhydrase inhibitors are part of established protocols at many centers. Most experts also recommend high-dose steroid therapy as a standard of care. Less agreement exists for use of topical beta-blockers and multiple osmotic agents.
• Irreversible optic-nerve pathology may occur with as little as 2 hours of ischemia. Rapid employment of medical therapy and ophthalmologic consultation should proceed promptly with diagnosis.
• Lateral canthotomy/inferior cantholysis^1,4
  • Emergent decompressive surgery for severe symptoms (eg, decreased visual acuity) may save sight.
  • ED physicians should be familiar with this procedure if emergent ophthalmologic consultation is unavailable (see Emergency Department Care).
• The emergency procedure of choice for acute visual acuity loss associated with acute orbital compartment syndrome is dissection of the lateral canthus and disinsertion of at least the inferior crus of the lateral canthal tendon, which allows complete mobility of the lower lid. Visual loss without clear signs consistent with increased IOP is not an indication for this procedure. Other primary indications for lateral canthotomy and cantholysis include an IOP greater than 40 mm Hg and proptosis, which may be used as a criterion for unconscious patients whose visual acuity cannot be determined. Secondary criteria include afferent pupillary defect, ophthalmoplegia, cherry-red macula, optic nerve head pallor, and severe pain, but these are all considered less sensitive or very late signs. Contraindication for this procedure would be a suspected ruptured globe.
• Perform lateral canthotomy, as follows (see Media file 1):
• 
  

  

  Lateral canthotomy is performed by incising laterally with sharp scissors.

  [ CLOSE WINDOW ]

  

  Lateral canthotomy is performed by incising laterally with sharp scissors.

  
  
  1. Clean the area with sterile saline.
  2. Inject approximately 1 mL of lidocaine 1-2% with or without epinephrine into the lateral canthus.
  3. Apply a hemostat/clamp with one side anterior and one side posterior to the lateral canthus and advance until the rim of the bony orbit is felt.
  4. Clamp for 30-60 seconds.
  5. Perform the lateral canthotomy by carefully cutting through the crushed, demarcated line to the orbital rim/lateral fornix to avoid traumatizing the orbit.
• Perform inferior catholysis by using one of the following methods (see Media file 2):
• 
  

  

  Cantholysis is performed by identification and disinsertion of the inferior crus of the lateral canthal tendon, which should allow free mobility of the lower lid margin.

  [ CLOSE WINDOW ]

  

  Cantholysis is performed by identification and disinsertion of the inferior crus of the lateral canthal tendon, which should allow free mobility of the lower lid margin.

  
  
  • Traditional approach: Grasp lower eyelid with forceps and pull out/downward away from eye. Identify the canthal ligament by either inspection or palpation. Incise the inferior crus of the lateral canthal ligament with scissors to avoid traumatizing the orbit.
  • The Sweep technique: Grasp the lower eyelid with forceps and pull out/downward away from eye. Carefully place the lateral side of an opened pair of curved scissors against the palpebral conjunctiva of the lateral eyelid. Slowly sweep laterally toward the canthotomy incision. When the inferior crus of the lateral canthal ligament is encountered impeding continued lateral sweeping, carefully move the other scissor blade into position and incise to avoid traumatizing the orbit. The sweep technique may be particularly useful in cases when massive edema makes canthal ligament identification difficult.
• Recheck the IOP, and dissect the superior crus in a similar fashion if an adequate decrease has not been achieved. Special care should be taken to avoid any trauma to the lacrimal gland.
  • In an experimental model, lateral canthotomy produced a mean IOP reduction of 14.2 mm Hg; isolated disinsertion, 19.2 mm Hg; and combined, 30.4 mm Hg.
  • Other methods to reduce IOP, including anterior chamber paracentesis and insertion of a mosquito clip inferiorly to break through the inferior orbital floor, are beyond the scope of this discussion.
• Immediately test visual acuity postprocedure. If vision fails to improve, as possibly expected in cases of confined subperiosteal hematoma, operative orbital decompression or hematoma evacuation should be considered.

Consultations

• Emergent ophthalmologic consultation is required in all cases.
• Emergent oromaxillary facial surgery consultation is required if the etiology is postsurgical and in all cases in which hemorrhage is suspected within the optic canal or optic nerve sheath.

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Hyperosmotic agents

These agents decrease IOP by direct osmosis of water.

Mannitol (Osmitrol, Resectisol)

Reduces elevated IOP when the pressure cannot be lowered by other means.

Carbonic anhydrase inhibitors

These agents decrease IOP by decreasing production of aqueous humor in anterior chamber. Additionally, they reduce systolic BP, which may help control hemorrhage.

Acetazolamide (Diamox)

Inhibits enzyme carbonic anhydrase, reducing rate of aqueous humor formation, which, in turn, reduces IOP. Used for adjunctive treatment of chronic simple (open-angle) glaucoma and secondary glaucoma and preoperatively in acute angle-closure glaucoma when delay of surgery is desired to lower IOP.

Corticosteroids

These agents exert an anti-inflammatory effect and an antioxidant effect that decreases production of free-radical metabolites.

Methylprednisolone (Solu-Medrol)

Reverses increased capillary permeability.

Beta-blockers

These agents decrease IOP by decreasing production of aqueous humor.

Timolol (Betimol, Timoptic)

May reduce elevated and normal IOP, with or without glaucoma by reducing production of aqueous humor.

Antiarrhythmic Agent, Class I-b

Anesthetics that inhibit depolarization of type C sensory neurons used.

Lidocaine

Amide local anesthetic used in 1-2% concentration. Inhibits depolarization of type C sensory neurons by blocking sodium channels.
Epinephrine prolongs effect and enhances hemostasis (maximum epinephrine dose 4.5-7 mg/kg).

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