Prompt intervention key in orbital injury

Burlington, VT—Early appropriate intervention can make a substantial difference in preventing permanent visual loss or diplopia when faced with a patient who has an orbital compartment syndrome or a white-eyed blowout fracture.

Knowing the signs and symptoms is crucial to ensuring appropriate and timely treatment, said David A. Weinberg, MD.

In the case of orbital compartment syndrome, the condition is characterized by a very tight orbit resulting from local tissue pressure that in turn compromises local tissue perfusion in the confined space of the orbit, Dr. Weinberg said. The orbital compartment is confined by the bones and the eyelids, which vary in elasticity and laxity from patient to patient.

"An accumulation of blood from an orbital hemorrhage, for example, can cause an increase in orbital pressure, as can air forced into the orbit during nose blowing in the presence of an orbital fracture, edema following orbital surgery, or pus within an orbital abscess," he added.

Visual loss in orbital compartment syndrome occurs because the fine perforating pial vessels that supply the retrobulbar optic nerve are at risk.

"These patients are more likely to be at risk of developing posterior ischemic optic neuropathy rather than central retinal artery occlusion," Dr. Weinberg said.

Orbital compartment syndrome is best managed by establishing a rapid diagnosis. In a patient with compromised vision and highly elevated IOP, treatment must be undertaken quickly.

Canthotomy and cantholysis is the first approach, according to Dr. Weinberg. This procedure begins with a horizontal incision that divides the lateral canthal tendon into a superior and inferior crux. A vertical cut is then made through the inferior limb of the lateral canthal tendon, which releases it.

If that proves insufficient to relieve the orbital compartment syndrome, Dr. Weinberg noted, the superior limb of the lateral canthal tendon should be divided.

"Orbital decompression surgery is rarely needed," he added. "In my experience, canthotomy and cantholysis generally suffice."