Occurrence of acute retrobulbar hemorrhage during birth.

OBJECTIVE: Presentation of acute retrobulbar subperiostal hemorrhage (hematoma) in the course of delivery. The occurrence, possible threats and recommended methods of treatment are described. Introduction: Acute retrobulbar hemorrhage is always a serious condition. Even if not connected with other ocular trauma, it could cause permanent blindness. The reason is based on constriction of the eye, decreasing of the blood supply and thus disruption of the oxygen supply to sensitive retinal tissues. After a short time, these tissues start to deteriorate and lose their natural function. This event is often connected with exophthalmia and diplopia. The primary diagnostic procedure is to measure intraocular pressure (IOP). Even if the ideal diagnostic tools are not accessible, performing a lateral canthotomy (event. with inferior cantholysis) is recommended to relieve IOP in acute situations. Normal intraocular pressure is considered to be 8-21 mmHg. Case report: Our 29-year-old female patient was in the second stage of delivery and suddenly got retrobulbar hemorrhage, resulting in exophthalmia and diplopia. Her baby was delivered shortly after the event. The following delivery course was normal, including her perineum repair and puerperium. Our patient was fortunate because her visual acuity and IOP were normal. Therefore, we chose an observational treatment strategy. After 5 weeks, we noted successful disintegration of the hematoma and decreased exophthalmia and diplopia without other consequences. Conclusion: We described retrobulbar subperiostal bleeding in our patient in the course of delivery. We depicted possible threats that could result in blindness and described recommended methods of treatment. Even if such a situation is extremely rarely, we believe that knowledge of these guidelines could help medical professionals broaden their treatment options. This particularly occurs when a trained eye surgeon is not available.

Retrobulbar hemorrhage with orbital compartment syndrome: A rare sight-threatening emergency during air medical evacuation.

Traumatic retrobulbar hemorrhage may be rapidly progressive, converts to a sight-threatening emergency with potentially devastating complications. Assisted-escape systems in fast jet aircraft can lead to the pilot's facial/orbital injuries at any stage of the ejection sequences, which may result in retrobulbar hemorrhage. Orbital traumas are common and rarely result in retrobulbar hemorrhage and orbital compartment syndrome. However, early diagnosis and urgent out-of-the-hospital lateral canthotomy with cantholysis were recommended to save the patient's vision.

Success rates of lateral canthotomy and cantholysis for treatment of orbital compartment syndrome.

PURPOSE: Vision loss after facial trauma can occur from orbital compartment syndrome (OCS). Orbital compartment syndrome is commonly treated surgically with a lateral canthotomy and cantholysis (C&C). Our study investigates success rates of lateral C&C for the treatment of OCS amongst emergency medicine (EM) and ophthalmology providers. METHODS: A retrospective cohort study was performed. Cases were identified and the electronic medical record of patients was interrogated for clinical and procedural information. Success of a lateral C&C was defined as a decrease in intraocular pressure (IOP) to <30 mmHg after the first attempt at the procedure. Inclusion criteria included documentation of a procedural attempt, a pre-procedure IOP >30 mmHg and a post-procedure IOP measurement; or alternatively if no pre-procedure IOP was documented but the IOP was >30 on arrival to the level 1 trauma center. Exclusion criteria included periprocedural use of ocular hypotensive medications and comorbid hyphema. RESULTS: The final analysis included 74 eyes from 64 patients. Emergency medicine providers performed the initial lateral C&C in 68% of cases compared to 32% by ophthalmologists, and success rates were comparable - 68% vs 79.2%, respectively (p = 0.413). Poorer visual outcomes were associated with the initial failure of a lateral C&C and head trauma without an orbital fracture. All patients treated with a vertical lid split procedure met the criteria for 'success' as defined by this study. CONCLUSIONS: The success rate of a lateral C&C is comparable amongst EM and ophthalmology providers. Improved training of physicians on the lateral C&C or other simpler procedures, such as the vertical lid split, could improve outcomes in OCS.

A Novel Simulation Model Significantly Improves Confidence in Canthotomy and Cantholysis Among Ophthalmology and Emergency Medicine Trainees.

BACKGROUND: Orbital compartment syndrome is a potentially blinding eye condition. Timely diagnosis and treatment are paramount to optimize visual outcomes. Lateral canthotomy and cantholysis is the definitive management and a required competency for emergency physicians and ophthalmologists. Lack of confidence in the procedure can result in delayed treatment and poor outcomes. OBJECTIVES: Our aim was to create a low-cost, realistic, simulation model to ensure trainees were confident in performing lateral canthotomy and cantholysis. METHODS: A model was created using equipment found in the emergency department. This model's efficacy was assessed using pre- and post-teaching questionnaires measuring learner's self-perceived confidence. RESULTS: Forty-seven emergency medicine and 18 ophthalmology registrars rated their confidence in the procedure using a 5-point Likert scale (1 = not very confident, 5 = extremely confident); 42% (n = 27) of participants felt 'quite confident' (4 on Likert scale) in carrying out the procedure unsupervised out of hours after the teaching session, compared with 9.23% (n = 6) before (p < 0.01). Our model resulted in significant increases in all three measures of confidence (diagnosing orbital compartment syndrome, locating the necessary equipment and performing canthotomy and cantholysis) and was rated as 4.35 (1 = not at all helpful, 5 = extremely helpful) in understanding the anatomy of the region. Sixty-six percent (n = 43) of participants stated they would like further simulation teaching. CONCLUSIONS: Our model is low cost, easy to assemble, and anatomically correct. The user can 'strum' the inferior canthal tendon without cutting the lower lid, appreciating the difference between canthotomy and cantholysis. Use of this model significantly increased the number of learners who felt "quite confident" with performing the procedure. Use of this model should be considered for trainees in ophthalmology and emergency medicine.

Orbital Compartment Syndrome and Irreversible Blindness Related to Orbital Varix Thrombosis: A Case Report.

BACKGROUND: Orbital compartment syndrome (OCS) is an ocular emergency that can severely threaten the visual potential. The most common etiologies include facial trauma-related orbital wall fractures and postoperative bleeding within the orbit. Nontraumatic cases were also reported sporadically, although they are rare. The orbital volume limits the compliance to expand when space-occupying lesions develop. Both direct compression of the optic nerve and depleted perfusion from elevated intraorbital pressure subsequently lead to ischemic optic neuropathy and vision loss. CASE REPORT: A 74-year-old man experienced headache, bulging left eye, dull pain, vision loss, nausea, and vomiting within 1 day. Computed tomography and magnetic resonance imaging revealed a heterogeneous mass extending from the orbital apex and connected with the ophthalmic vein. Lateral canthotomy and cantholysis were performed at bedside for emergent orbital decompression. The proptosis and pain relieved after surgery, but visual loss remained irreversible. Surgical exploration was conducted and pathology proved the diagnosis of varix of the ophthalmic vein with thrombosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of the presentation of OCS and perform timely orbital decompression, which could reverse visual impairment. These patients might also benefit from immediate consultants with ophthalmologists and radiologists.

Efficacy of vertical lid split versus lateral canthotomy and cantholysis in the management of orbital compartment syndrome.

Purpose: To compare the efficacy of the vertical lid split (VLS) to the standard lateral canthotomy and cantholysis (LC/C) for orbital compartment syndrome (OCS) in the cadaveric model.Methods: Simulated OCS was achieved in seven fresh frozen cadaveric orbits. Orbital pressure (OP) was monitored in one control orbit and six interventional orbits. Initial OP was recorded before three right orbits underwent lateral canthotomy with superior and inferior cantholysis, and three left orbits underwent vertical lid split of the upper and lower eyelids. In all 7 orbits, OP was recorded for a total of 16 min. The main outcome measure was the amount of OP reduction at timed intervals.Results: Beginning OP in the control orbit was 109 mmHg, and average initial OP of the LC/C and VLS orbits were 90 and 103 mmHg, respectively. The control orbit maintained high OP without intervention. One minute after LC/C, OP decreased an average of 58.7 mmHg (65.2%; range 48-65 mmHg). One minute following VLS, OP decreased an average of 63 mmHg (61.0%; range 39-102 mmHg). At 16 min, OP reduction in the LC/C orbits averaged 65.3 mmHg (72.6%; range 56-71 mmHg), and OP reduction in the VLS orbits averaged 78 mmHg (75.5%; range 54-121 mmHg). Both interventions produced a comparable reduction in OP.Conclusions: Vertical lid split was found to be as effective as LC/C in reducing OP. The technical simplicity of the VLS lends itself well to utilization by physicians who are unfamiliar with eyelid surgery.

A human cadaveric model for effective instruction of lateral canthotomy and cantholysis.

Purpose: To evaluate a human cadaveric model in improving knowledge and comfort of ophthalmology residents performing a lateral canthotomy/cantholysis.Methods: A prospective study was conducted in ophthalmology residents, who participated in a workshop including an interactive lecture followed by hands-on training on a human cadaver. The lecture consisted of the indications and techniques of lateral canthotomy/cantholysis, along with video-demonstration of proper technique. Residents practiced the procedure on cadavers under faculty supervision. Knowledge and comfort level of conducting the procedure was assessed pre- and post-workshop.Results: Post-workshop, the residents showed a significant improvement in general knowledge regarding the technique of the procedure. Pre-workshop, the average knowledge score was 9 points out of 18 and this improved post-workshop to 12 points out of 18 (p < 0.0001). Residents showed a significant improvement in comfort levels performing the procedure. Using a Likert scale, the average comfort level of performing the procedure rose from 2.5 (Fair) prior to the workshop to 4 (Very Good) post-workshop (p = <0.01). All participants reported an average score of 4.91 (1 = Strongly Disagree, 5 = Strongly Agree) that the human model workshop was clinically applicable to their training and would impact the quality and safety of patient care.Conclusion: The study demonstrated an increase in knowledge and comfort in performing lateral canthotomy and cantholysis using a cadaver model. With the time-sensitive nature of orbital compartment syndrome, it is imperative that physicians are comfortable in performing this procedure to prevent permanent vision loss.

A Historical Perspective of Lateral Canthotomy and Its Adoption as an Emergency Medicine Procedure.

BACKGROUND: The treatment of orbital compartment syndrome has a rich history rooted in surgery and emergency medicine. It is a rare but acute and vision-threatening condition that most commonly occurs secondary to facial trauma or as a postoperative complication, and was first recognized in 1950. Surgical techniques and medical management were developed and refined soon afterwards to eventually become the modern-day treatment, lateral canthotomy, and inferior cantholysis. OBJECTIVE: This article details the history of orbital compartment syndrome and the evolution of its treatment to the present day. DISCUSSION: Given the time-sensitive nature and acuity of orbital compartment syndrome, lateral canthotomy was adopted by emergency physicians who could perform it more quickly at the bedside. CONCLUSIONS: Lateral canthotomy is a procedure adopted by emergency physicians from the surgical literature. The history of its adoption is a representative example of how emergency medicine evolves as a field.

Ocular Compartment Syndrome and Lateral Canthotomy Procedure.

BACKGROUND: Ocular compartment syndrome (OCS) is a serious ophthalmological emergency that should be diagnosed and treated immediately to prevent permanent loss of vision. It is usually caused by a retro-orbital bleed that will subsequently increase intra-orbital pressure and threaten the patient's vision. Lateral canthotomy and cantholysis is a minor bedside procedure using simple equipment that is readily available in emergency departments, and the aim of such a procedure is to free the eye globe from its lateral attachment to the bony orbital wall and allow more eye protrusion and hence reduce intra-orbital pressure and save the patient's sight. The case we present describes a 42-year-old man who presented with facial injuries following an alleged assault and in whom a computed tomography scan of the head showed a retro-orbital hemorrhage. The patient had subtle signs of increased intra-orbital pressure for which lateral canthotomy and cantholysis was indicated. DISCUSSION: OCS is an ophthalmological emergency that can present with subtle signs of increased intraocular pressure that can lead to irreversible loss of vision if not treated with a simple bedside operation called lateral canthotomy and cantholysis within a specific time frame. We explore the pathophysiology and presentation of OCS and how to perform the lateral canthotomy with cantholysis procedure. CONCLUSIONS: The aim of this case presentation is to highlight the importance of diagnosing OCS as an ophthalmological emergency and discuss how to perform the sight-saving procedure.

Oculocardiac Reflex as a Result of Intraorbital Trauma.

BACKGROUND: The oculocardiac reflex is a decrease in heart rate caused by ocular compression or traction upon the extraocular musculature. Multiple instances of this phenomenon have been described in anesthesia, trauma, craniofacial, and ophthalmology literature, but there is a sparsity of documentation in the emergency medicine literature. CASE REPORT: We describe the observation and management of the oculocardiac reflex in a 26-year-old man with retrobulbar hematoma and intraocular trauma caused by a self-inflicted gunshot wound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Prompt recognition of the oculocardiac reflex is important for the emergency physician given the common occurrence of craniofacial trauma and the potentially devastating consequences if not recognized and addressed.

Orbital Compartment Syndrome: Alternative Tools to Perform a Lateral Canthotomy and Cantholysis.

Orbital compartment syndrome acutely threatens vision. Lateral canthotomy and cantholysis ameliorate the compartment syndrome and, to save a patient's vision, must be performed in a timely manner. This requires appropriate tools. In resource-poor settings, the straight hemostat and iris scissors that are generally used for this procedure may be unavailable. In such situations, safe alternatives include using a multitool in place of a hemostat and a #11 scalpel blade instead of the iris scissors. As when using hemostats of varying sizes, the pressure applied to the multitool must be carefully modulated. When using a scalpel blade for the lateral canthotomy, the hemostat arm remains beneath the lateral canthus as a "backstop" to protect deeper tissues. For the cantholysis, use the back of the blade to "strum" for the ligaments, reversing its direction only to cut the ligament when it is identified.

Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome.

BACKGROUND: Orbital compartment syndrome is a sight-threatening emergency. Vision may be preserved when timely intervention is performed. OBJECTIVE: To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration. DISCUSSION: Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome. CONCLUSIONS: Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss.

Emergency management of orbital compartment syndrome: Lateral canthotomy and cantholysis case series.

BACKGROUND: Orbital compartment syndrome (OCS) is considered a time critical condition that requires urgent surgical decompression to preserve vision. This study aims to evaluate the current clinical criteria for performing a lateral canthotomy and cantholysis (LCC) in the emergency management of suspected traumatic OCS. METHODS: A retrospective audit of patients with suspected traumatic OCS presenting to an adult major trauma centre between January 1, 2017, and August 1, 2022, was performed. RESULTS: 20 patients with traumatic OCS treated with a LCC were identified. Five patients satisfied the definitive clinical criteria for LCC. The remaining 15 patients received LCC based on secondary clinical findings, or computed tomography (CT) findings suggestive of OCS. 17 patients received non-contrast CT scanning prior to LCC. Of the nine patients noted to regain baseline or close to baseline vision, only one was decompressed within two hours of injury. CONCLUSION: Despite OCS being a clinical diagnosis, the signs and symptoms associated with OCS are difficult to elicit on presentation. Seeking imaging should not delay time to decompression when clinical diagnostic criteria are present. However, imaging may have a role in determining the need for orbital decompression where the absolute indications for LCC cannot be adequately assessed.

Unusual presentation of orbital compartment syndrome due to complicated herpes zoster ophthalmicus: A case report.

Herpesvirus reactivates from a latent infection in older adults and critically ill and immunocompromised individuals. Herpes zoster ophthalmicus (HZO) is a latent infection that affects the fifth cranial nerve. It is an infrequent cause of increased intraocular pressure. We present the case of a 50-year-old man with a reactivation of latent varicella-zoster virus infection involving the ophthalmic branch of the fifth cranial nerve. The patient was initially managed as an outpatient with an antiviral, but his clinical evolution worsened and required urgent surgical decompression. Lateral canthotomy was performed with cantholysis of the inferior crus of the lateral canthal tendon. Only partial decompression was achieved, so cantholysis of the upper crus was performed with significant tissue tension release. The patient evolved well and was discharged after 6 days without symptoms for outpatient management.

Acute orbital compartment syndrome due to traumatic hemorrhage: 4-year case series and relevant literature review with emphasis on its management.

PURPOSE: Blindness in craniomaxillofacial (CMF) injuries may occur due to acute orbital compartment syndrome (AOCS). Primarily, this article aimed to retrospectively review our 4-year experience in the management of patients diagnosed with AOCS secondary to an orbital hematoma (OH). Furthermore, this paper included up-to-date information regarding the prevalence, diagnosis, management, and prognosis of AOCS. MATERIALS AND METHODS: We retrospectively screened the medical records of patients who visited our hospital's emergency department (ED) and were examined by an oromaxillofacial surgeon for CMF injuries, between September 1, 2013, and September 31, 2017. The electronic hospital's database was searched to retrieve all cases of CMF trauma admitted or referred to our clinic during this period. RESULTS: Over a 49-month period, 3,514 patients were managed for CMF injuries in ED; 9 cases (0.26%) were attributed to OCS caused by an OH. This group comprised 5 males and 4 females aged between 32 and 91 years old (mean 65.7, median 70). Seven out of 9 patients were subjected to lateral canthotomy and inferior cantholysis (LCIC), whereas septolysis was applied in 6 of them. Sight was preserved in 3 out of 8 patients (37.5%), since a patient died from a serious intracranial injury. Seven out of 9 patients (77.7%) of the OCS group had a history of hypocoagulable state. CONCLUSIONS: LCIC, septolysis, and careful dissection within inferotemporal orbital quadrant constitute a reliable approach for emergent orbital decompression. CT scan offers differential diagnosis of acute traumatic proptosis, but it should preferably follow LCIC. In case of OHs without pupillary abnormalities and/or impairment of visual acuity, close monitoring allowing for timely interventions is highly recommended to patients with a history of hypocoagulative status, (uncontrolled or severe) hypertension, head trauma, and decreased level of consciousness or in elderly patients suffering from dementia or without rapid access to follow-up medical care. Clinicians dealing with ED services must maintain high skills in AOCS diagnosis and in LCIC execution.

Prehospital canthotomy: A sight-saving procedure in case series.

OBJECTIVE: Orbital compartment syndrome (OCS) is a time critical condition, with ischaemic complications occurring after 90-120 min. In the prehospital setting, the diagnosis and management of OCS is challenging due to complex environmental considerations, competing clinical priorities, and limited equipment. This study aims to provide learning points on performing lateral canthotomy and cantholysis (LCC) in the prehospital setting. METHODS: We performed a retrospective audit of LCC in our service from January 2016 to December 2020 by retrieving demographic and clinical details from LifeFlight Retrieval Medicine electronic database using 'OCS' and 'LCC' as keywords. RESULTS: Three cases out of 7413 trauma missions were identified over the 5-year period. LCC was performed at the primary scene in two cases, while one patient underwent LCC at a rural hospital near the scene of injury. Clinical findings, aeromedical considerations, and radiological findings at the receiving facility, along with visual outcomes at time of discharge are discussed. CONCLUSION: Prehospital LCC is rare. The Australian aeromedical context often involves lengthy transfers of trauma patients. Clinical diagnosis and management of OCS are highly challenging in the prehospital setting. It is important that prehospital physicians have access to appropriate equipment to perform LCC. They should be provided with suitable training and supported by a standard operating procedure.

Carotid cavernous fistula secondary to ruptured carotid cavernous aneurysm causing orbital compartment syndrome.

PURPOSE: To report the rare presentation of orbital compartment syndrome secondary to formation of carotid cavernous fistula in the absence of trauma or surgery and demonstrate the role of emergent canthotomy/cantholysis as a vision saving procedure. OBSERVATIONS: A 28-year-old African American female with obesity and migraines presented to the emergency department (ED) with the worst headache of her life after a severe episode of vomiting and dry heaving. Initial CT scan was negative for subarachnoid hemorrhage and patient was discharged. She re-presented to ED several days later with worsening proptosis and left eyelid edema and was discharged on oral antibiotics for presumed preseptal cellulitis after repeat CT scan. When seen by Ophthalmology in clinic, she was noted to have decreased vision, proptosis, decreased color perception, and double vision. She was noted to have orbital compartment syndrome requiring emergent canthotomy/cantholysis in the minor OR. She was sent back to ED for work-up, ultimately revealing a carotid cavernous fistula secondary to rupture of a carotid cavernous aneurysm. She was treated with several coil embolization procedures and ultimately her visual acuity rebounded to 20/20. CONCLUSIONS AND IMPORTANCE: Orbital compartment syndrome may be a rare presentation of carotid cavernous fistula secondary to ruptured carotid cavernous aneurysm in the absence of trauma or surgery. Our case demonstrates the importance of properly assessing the cause of a red, edematous, proptosed eye in clinical setting and initiating an appropriate workup and treatment plan without delay.

Surgical Approaches to the Orbit: Transpalpebral.

The aim of this study is to provide an overview of the safe and effective incisional transpalpebral approaches to the orbit. The location of each approach and pertinent anatomy in each respective area, suggested approach techniques, recommended specialties, reconstruction options, intraoperative neurophysiology, complications, and approach limitations are discussed in detail.

Emergency canthotomy and cantholysis - Factors affecting confidence among ophthalmic trainees in the United Kingdom.

PURPOSE: Retrobulbar hemorrhage from trauma is the most common cause of orbital compartment syndrome. Emergency canthotomy and cantholysis is a vision-saving procedure. We sought to identify confidence among ophthalmic trainees in this procedure as well as any relevant factors that have any impact. METHODS: An online, confidential anonymous questionnaire was distributed to ophthalmology training groups in the UK. Questions explored the participant's stage of training and grade and confidence in this area as well as their ophthalmic experience in terms of training courses attended and elective versions of the procedure performed. RESULTS: We received 45 completed responses from the survey. 20/23 (87%) of junior trainees had not performed an emergency canthotomy/cantholysis to date, whereas 19/22 (86%) of senior trainees had performed between 1 and 5 such procedures. 15/23 (65%) of junior trainees had not performed an elective canthotomy compared to only 3/22 (14%) of the senior trainees. We found that the main factors that were associated with increased confidence level were the higher numbers of emergency and elective cases performed, training courses, and previous oculoplastic surgery rotation (P = 0.0001). CONCLUSION: From our survey, we found low confidence levels among junior trainees due to limited exposure. Confidence appeared to be linked to both elective and emergency surgical experience of the procedure as well as training course and having worked in an oculoplastic surgery firm. Changes to training portfolio requirements for junior trainees to incorporate early oculoplastic experience may help to achieve this on a national scale.

Orbital compartment syndrome: Pearls and pitfalls for the emergency physician.

Orbital compartment syndrome (OCS) is a rare, vision-threatening diagnosis that requires rapid identification and immediate treatment for preservation of vision. Because of the time-sensitive nature of this condition, the emergency physician plays a critical role in the diagnosis and management of OCS, which is often caused by traumatic retrobulbar hemorrhage. In this review, we outline pearls and pitfalls for the identification and treatment of OCS, highlighting lateral canthotomy and inferior cantholysis (LCIC), a crucial skill for the emergency physician. We recommend adequate preparation for the diagnosis and procedure, early consultation to ophthalmology, clear and thorough documentation of the physical examination, avoidance of iatrogenic injury during LCIC, and complete division of the inferior canthal tendon. Emergency physicians should avoid failing to make the diagnosis of OCS, delaying definitive surgical treatment, overrelying on imaging, failing to decrease intraocular pressure, and failing to exclude globe rupture. The emergency physician should be appropriately trained to identify signs and symptoms of OCS and perform LCIC in a timely manner.