Orbital compartment syndrome
Background[1]
- Rare, vision-threatening ophthalmic emergency characterized by an acute elevation of intra-orbital pressure which exceeds the vascular perfusion pressure of the ophthalmic artery.
- Most commonly caused by acute orbital or facial trauma
- Less common causes include local injections, orbital infection, orbital emphysema, foreign bodies, and spontaneous hemorrhage
Clinical Features
- Decreased visual acuity
- Afferent pupillary defect
- Difficulty opening eyelids
- Limited motility
- Proptosis
Differential Diagnosis[2]
- Retinal detachment
- Globe rupture
- Endophthalmitis
- Optic nerve decompression
- Anterior ischemic optic neuropathy (AION)
Periorbital swelling
Proptosis
- Normal IOP
- Orbital cellulitis
- Orbital pseudotumor
- Orbital tumor
- Increased IOP
- Retrobulbar abscess
- Retrobulbar emphysema
- Retrobulbar hemorrhage
- Ocular compartment syndrome
- Orbital tumor
No proptosis
- Periorbital cellulitis/erysipelas
- Dacryocystitis (lacrimal duct)
- Dacryocele/Dacryocystocele
- Dacryostenosis
- Dacryoadenitis (lacrimal gland)
- Allergic reaction
- Nephrotic Syndrome (pediatrics)
Lid Complications
- Blepharitis (crusts)
- Chalazion (meibomian gland)
- Stye (hordeolum) (eyelash folicle)
Other
- Subperiosteal abscess
- Orbital abscess
- Cavernous sinus thrombosis
- Conjunctivitis
- Contact dermatitis
- Herpes zoster
- Herpes simplex
- Sarcoidosis
- Granulomatosis with polyangiitis
Evaluation
Workup
Do NOT delay treatment for diagnostic studies if there is already a high clinical suspicion for OCS
- Tonometry (Tono-pen)
- Do NOT use until globe rupture has been excluded
- Normal pressure 10-20mmHg; pressure >35mmHg suggests OCS[3]
- Labs
- CBC/BMP (if history of trauma or cellulitis)
- Coag panel (coagulopathy increases risk for retrobulbar hemorrhage)
- Imaging
- CT (Orbit)
- May help identify etiology or exclude diagnoses
- 75% of OCS cases will show a change in posterior globe configuration ("globe tenting")
- Ultrasound (orbit)
- Not been validated for AOCS, but may identify other ocular pathologies (retinal detachment, central retinal artery occlusion, lens dislocation, vitreous hemorrhage, and vitreous detachment[4]
- CT (Orbit)
Diagnosis
- Diagnosis can made clinically with afferent pupillary defect, vision loss, and intraocular pressure >35mmHg
Management
- Definitive therapy is lateral canthotomy and inferior cantholysis(LCIC)
- Emergent ophthalmology consultation
- Consider adjunctive medical therapy:
- 20% mannitol 2 g/kg IV
- methylprednisolone, 250mg IV or hydrocortisone 100mg IV
- acetazolamide, 250 to 500mg IV
Disposition
- Admit
See Also
External Links
- REBEL EM (https://rebelem.com/orbital-compartment-syndrome-pearls-and-pitfalls-for-the-ed-physician/)
References
- ↑ Murchison, A., 2021. Orbital Compartment Syndrome - EyeWiki. [online] Eyewiki.org. Available at: <https://eyewiki.org/Orbital_Compartment_Syndrome> [Accessed 29 June 2021].
- ↑ Shannon, B., 2019. Acute Orbital Compartment Syndrome Differential Diagnoses. [online] Emedicine.medscape.com. Available at: <https://emedicine.medscape.com/article/799528-differential> [Accessed 29 June 2021].
- ↑ Stiff, H., 2018. Orbital Compartment Syndrome Curriculum. [online] Eyerounds.org. Available at: <https://eyerounds.org/tutorials/ocs/index.htm> [Accessed 29 June 2021].
- ↑ Blavias, M., 2002. A study of bedside ocular ultrasonography in the emergency department.. [online] Reference.medscape.com. Available at: <https://reference.medscape.com/medline/abstract/12153883> [Accessed 29 June 2021].