Trans-tarsal Stair-Step Technique for Lateral Extension of the Transconjunctival Incision: A Technical Note and Case Series.

Background: The transconjunctival approach paired with lateral canthotomy is a commonly used technique for widened exposure of the orbital floor and infraorbital rim. A major drawback of this approach is the severance of lateral canthal ligament fibers, which predisposes to potential postoperative eyelid malpositioning. To avoid these suboptimal aesthetic outcomes, a modification of this approach has been proposed in which the lower eyelid is mobilized with a paracanthal, trans-tarsal stair-step incision. In this pilot study, we describe our experience with the trans-tarsal stairstep incision for lateral extension of the transconjunctival incision and report its outcomes in a Western population. Methods: All patients who underwent facial fracture operative fixation at a single institution by a single senior surgeon were included. Clinical variables were extracted. Patients were stratified by incision type. Results: Compared with patients who underwent subtarsal incision (n = 20) and transconjunctival incision with lateral canthotomy (n = 4), patients who received the trans-tarsal stair-step incision (n = 10) had no incision-related complications or requirements for revision. The most common complications found in the comparison groups were ectropion and hypertrophic or irregular scarring, and 4 patients required revision. Conclusions: Our initial experience with the transconjunctival approach with the trans-tarsal stair-step incision shows promising outcomes. Further study may promote greater utilization of this technique in Western countries.

Fatal Viscerocutaneous Brown Recluse Envenomation With Orbital Compartment Syndrome.

Loxosceles is an arachnid genus comprising several species in the United States, popularly known as brown recluse spiders. The venom is cytotoxic, complex, and has a mixture of many proteins, some of which function as proteases. Envenomation can cause necrotic skin lesions that may become extensive and take many months to heal. Even more rarely, venom may cause systemic effects, leading to widespread hemolysis, coagulopathy, and death. These symptoms typically occur rapidly within 24-48 hours following the bite. We describe a rare case of a 44-year-old male with fatal systemic loxoscelism with orbital compartment syndrome requiring emergent lateral canthotomy and cantholysis.

Diagnosis and Management of Orbital Compartment Syndrome in Burn Patients - a Systematic Review.

Orbital compartment syndrome is a poorly understood complication of acute burns. The purpose of this systematic review is to summarize the literature describing orbital compartment syndrome in burn patients to provide greater detail on risk factors and guide management of this morbid condition. A systematic review of the PubMed, Embase, and Cochrane Library databases was performed in June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using two validated scoring systems. After removing duplicates, 303 unique articles were reviewed and 8 met inclusion criteria. All publications were retrospective. Most studies considered intraocular pressure >30-40mmHg as diagnostic for orbital compartment syndrome. Sixty unique cases of orbital compartment syndrome were reported. Orbital compartment syndrome occurred most frequently within 24 hours post-burn. The mean total body surface area of burn was 58.7%; the mean 24-hour resuscitation volume was 6.01 cc/kg/%total burn surface area; and 86.5% of cases had periorbital burns. Surgical decompression always started with lateral canthotomy. When pressures were not immediately reduced, cantholysis was performed. Study quality per Median Newcastle Ottawa Scores ranged from 38.9% to 94.4% (median 66.7%). A precise threshold for surgical decompression of OCS remains conflicted; however, IOP>30-40mmHg warrants intervention. Burn surgeons/intensivists should be aware of the risk factors for this vision-threatening complication and act appropriately.

Rapid progression of orbital abscess requiring lateral canthotomy in a pediatric patient.

Subperiosteal abscess (SPA) is a rare complication of acute sinusitis in children that may develop rapidly. In this case report, we describe an 11 year-old boy who presented with a large SPA 2 days after being diagnosed with conjunctivitis. The patient required emergent lateral canthotomy and cantholysis (LCC), IV antibiotics, and emergent surgery. It is crucial that emergency physicians be able to identify and treat this vision-threatening complication.

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.

Cirurgia de enucleação em decorrência de proptose do globo ocular em cadela: relato de caso / Enucleation surgery due to proptosis of the eyeball in a female dog: case report / Cirugía de enucleación por proptosis del globo ocular en una perra: informe de un caso

A proptose do globo ocular é uma das consequências comuns do trauma e a enucleação é um procedimento de escolha em caso de impossibilidade de reversão do quadro. Nota-se a infrequência de relatos de enucleação do globo ocular resultante de proptose traumática, o que torna importante a descrição deste caso, a qual objetiva fornecer relevantes informações e contribuições para o desenvolvimento da oftalmologia e clínica cirúrgica veterinária. Uma cadela filhote foi atendida no HVU - UFPI/CPCE, apresentando o globo ocular direito prolapsado. A enucleação foi selecionada em decorrência do intervalo prolongado entre a detecção da lesão e a busca por assistência médica, da presença de uma alta carga de corpos estranhos observados e da ausência de reflexos pupilares. A cirurgia iniciou-se com a cantotomia seguida da dissecação da musculatura do globo ocular. Foi realizado o pinçamento dos vasos sanguíneos e do nervo óptico, e fez-se a ressecção do globo ocular. Depois de uma ligadura invaginante e redução do espaço morto, removeu-se as bordas palpebrais e realizou-se a blefarorrafia. Cerca de 40 dias após a enucleação, a cadela apresentou-se estável e com uma evolução cicatricial satisfatória do ferimento cirúrgico. Esse procedimento, foi realizado de forma semelhante ao que é visto na literatura, embora, majoritariamente, seja recomendada a enucleação em decorrência de afecções diferentes da proptose traumática.

Proptosis of the eyeball is one of the common consequences of trauma and enucleation is the procedure of choice if it is impossible to reverse the condition. There are few reports of enucleation of the eyeball resulting from traumatic proptosis, which makes it important to describe this case, which aims to provide relevant information and contributions to the development of ophthalmology and veterinary surgical practice. A female puppy was seen at the HVU - UFPI/CPCE, presenting with a prolapsed right eyeball. Enucleation was selected due to the prolonged interval between detecting the lesion and seeking medical assistance, the presence of a high foreign body burden and the absence of pupillary reflexes. Surgery began with canthotomy followed by dissection of the eyeball muscles. The blood vessels and optic nerve were clamped and the eyeball was resected. After an invaginating ligature and reduction of the dead space, the eyelid edges were removed and blepharorrhaphy was performed. Around 40 days after enucleation, the dog was stable and had satisfactory healing of the surgical wound. This procedure was carried out in a similar way to that seen in the literature, although enucleation is mostly recommended for conditions other than traumatic proptosis.

La proptosis del globo ocular es una de las consecuencias comunes de los traumatismos y la enucleación es el procedimiento de elección si es imposible revertir la condición. Existen pocos relatos de enucleación del globo ocular resultante de proptosis traumática, lo que torna importante la descripción de este caso, que pretende proporcionar informaciones relevantes y contribuciones para el desarrollo de la oftalmología y de la práctica quirúrgica veterinaria. Una cachorra fue atendida en el HVU - UFPI/CPCE con prolapso del globo ocular derecho. Se optó por la enucleación debido al prolongado intervalo entre la detección de la lesión y la búsqueda de asistencia médica, la presencia de una elevada carga de cuerpo extraño y la ausencia de reflejos pupilares. La cirugía comenzó con una cantotomía seguida de la disección de los músculos del globo ocular. Se pinzaron los vasos sanguíneos y el nervio óptico y se resecó el globo ocular. Tras una ligadura invaginante y la reducción del espacio muerto, se retiraron los bordes de los párpados y se realizó una blefarorrafia. Unos 40 días después de la enucleación, el perro estaba estable y la herida quirúrgica había cicatrizado satisfactoriamente. Este procedimiento se llevó a cabo de forma similar a lo visto en la bibliografía, aunque la enucleación se recomienda sobre todo para afecciones distintas de la proptosis traumática.

Surgical exposure for vitrectomy in retinopathy of prematurity.

Our purpose was to evaluate the efficacy of lateral canthotomy, sub-tenon anesthesia injection, and the use of modified speculum for gaining adequate surgical exposure during surgery for retinopathy of prematurity (ROP). Fourteen eyes of 10 consecutive patients undergoing microincisional vitrectomy surgery (MIVS) for stage 4 and stage 5 ROP were included. There was a significant widening of the palpebral fissure height and length using this technique. No patient developed a lens injury during the surgery. All the canthotomy incisions completely healed at a four-week follow-up visit. This is a safe and effective technique for increasing surgical exposure in cases of ROP requiring vitrectomy.

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.

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.

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.

Retrobulbar hemorrhage decompression with paracanthal "one-snip" method: Time to retire lateral canthotomy?

Orbital compartment syndrome is a rare but serious condition most commonly as a result of traumatic retrobulbar hemorrhage and must be treated quickly to avoid ischemic damage to the optic nerve and retina. While the previously accepted standard of care for management of this condition has been lateral canthotomy with inferior cantholysis, this procedure can be challenging for physicians to perform given the rarity of the condition and that patients are frequently in significant pain often with significant periocular edema. In this case, orbital compartment syndrome was effectively treated with a paracanthal "one-snip" incision quickly and efficiently in the ED. This procedure offers a more manageable alternative treatment which has been found to produce a satisfactory intraocular pressure reduction in both cadaver models and now a patient with confirmed retrobulbar hemorrhage and resultant orbital compartment syndrome.

The Big Five-Lifesaving Procedures in the Trauma Bay.

Although resuscitation in trauma requires a multidisciplinary and multifaceted approach, one of the Big Five procedures may need to be performed as lifesaving and improving intervention. Your patient's lives depend on understanding, timing, and techniques of these elusive and difficult-to-master procedures. This article focuses on and reviews these five critical procedures: cricothyroidotomy, burr hole craniotomy, resuscitative thoracotomy, emergent hysterotomy, and lateral canthotomy. Prepare the team, system, and yourself when performing any of these procedures. It is important to be facile with your equipment and familiar with the steps to maximize success.

Orbital and Intracranial Emphysema Causing Orbital Compartment Syndrome: A Rare Case Report and Literature Review.

A case of 50-year-old male who presented with orbital compartment syndrome as a sequela of mid facial trauma, and literature review. Orbital compartment syndrome (OCS) is one of the potentially sight threatening emergencies encountered in clinical practice. Acute rise in pressure within the confined orbital cavity compromises the blood flow to retina and optic nerve leading to irreparable vision loss. Air entrapped in the orbital cavity leading to orbital compartment syndrome has been rarely reported. A brief literature search for the term orbital emphysema in PubMed yielded 352 articles out of which 280 articles were identified after screening for appropriate titles and case reports. A total of 138 patients were reported in the literature with severe orbital emphysema. Acute orbital compartment syndrome needs to be recognized and addressed on an emergency basis to achieve decompression so as to prevent an irreversible vison loss. Watchful eyes, an accurate diagnosis and timely surgical intervention could potentially reverse permanent damage to the optic nerve.

Cantolisis Lateral como Complemento al Acceso Transconjuntival en Fracturas de Órbita, Reporte de Casos

El acceso transconjuntival asociado a cantotomía lateral ha sido utilizado para permitir una mejor visualización de fracturas del piso de órbita. Esta técnica ha reportado entropión, ectropión y complicaciones en el reposicionamiento tarsal. Para disminuir la morbilidad descrita, hemos complementado este acceso con otra técnica denominada "Cantolisis Lateral" la que ha sido ampliamente utilizada como tratamiento de urgencia para hematoma retrobulbar, con pocos reportes sobre su utilidad en el tratamiento de las fracturas orbitarias. Reportamos los resultados post operatorios de la aplicación de la técnica cantolisis lateral como complemento al acceso transconjuntival en una serie de casos de 16 pacientes. La distopía cantal y la discontinuidad del tarso inferior fueron las complicaciones más frecuentes reportadas. Sin embargo, los pacientes no se percataron de ellas. No se reportaron ectropión ni entropión.

Transconjunctival approach associated with lateral canthotomy has been used to allow a better visualization of orbital floor fractures. This technique has reported entropion, ectropion and complications in tarsal repositioning. To decrease the described morbidity, we have complemented this approach with another technique called "Lateral Cantholysis" which has been widely used as an emergency treatment for retrobulbar hematoma, with few reports about its usefulness in the treatment of orbital fractures. We report the postoperative results of the application of the lateral cantholysis technique as a complement to the transconjunctival approach in a case series of 16 patients. Cantal dystopia and lower tarsal discontinuity were the most frequent complications reported. However, patients were not aware of them. No ectropion or entropion were reported.

Hematoma orbitario secundario a cirugía endoscópica nasosinusal / Orbital hematoma secondary to endoscopic sinus surgery

Resumen Durante la cirugía endoscópica nasosinusal, la sección inadvertida y retracción hacia la órbita de la arteria etmoidal anterior (AEA) es el mecanismo habitual del hematoma orbitario (HO); éste se manifiesta con proptosis, dolor y déficit visual potencialmente irreversible. El déficit visual es secundario a isquemia del nervio óptico por aumento de la presión intraocular, siendo suficientes treinta minutos para que ocurra daño visual permanente. Por sus secuelas el tratamiento del HO debe ser rápido y agresivo. Presentamos el caso de un varón de 72 años con diagnóstico de rinosinusitis crónica con pólipos nasales refractaria a tratamiento médico que se sometió a cirugía endoscópica nasal y que desarrolló en el posoperatorio inmediato con un HO. Se manejó precozmente con cantotomía-cantolisis, descompresión orbitaria medial endoscópica y control vascular de la AEA. El paciente evoluciona favorablemente, sin déficit visual. En este artículo se discutirán el diagnóstico y manejo oportunos del hematoma orbitario iatrogénico.

Abstract During endoscopic sinonasal surgery, inadvertent section of the anterior ethmoidal artery (AEA) with retraction into the orbit is the usual mechanism of orbital hematoma (OH), leading to proptosis, pain, and potentially irreversible visual loss. Thirty minutes is sufficient for retinal ischemia and permanent visual loss. The explanation for blindness is due to increased intraorbital pressure. The treatment of iatrogenic HO must be quick and aggressive, because if it is not managed in time, it can cause a permanent visual deficit. We present the case of a 72-year-old man with a diagnosis of chronic rhinosinusitis with nasal polyps refractory to medical treatment who underwent nasal endoscopic surgery, evolving in the immediate postoperative period with an HO, requiring canthotomy - cantolysis and early surgical reintervention for endoscopic medial orbital decompression and vascular control of AEA. The patient evolves favorably, without visual deficit. This article will discuss the timely diagnosis and management of iatrogenic orbital hematoma.

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.

Hemorragia retrobulbar espontánea asociada a consumo de anticoagulantes / Spontaneous retrobulbar haemorrhage associated with anticoagulants

La hemorragia retrobulbar es un sangrado en la región intraorbitaria retroseptal que genera un síndrome compartimental orbitario. Se presenta el caso de una mujer de 86 años que acudió a Urgencias por dolor ocular y pérdida de visión en ojo izquierdo de seis horas de evolución. Presentaba tratamiento anticoagulante con 300 mg/día de Dabigatrán por fibrilación auricular como único antecedente médico. La exploración clínica fue compatible con hemorragia retrobulbar, diagnóstico confirmado por TAC urgente, realizándose de forma inmediata una cantotomía con cantolisis. Se realizó RMN orbitaria que descartó la existencia de malformaciones arteriovenosas como factor desencadenante, diagnosticándose de hemorragia retrobulbar espontánea asociada a consumo de anticoagulantes. La singularidad de este caso radica en formar parte del pequeño porcentaje de hemorragias retrobulbares que no se asocian a causa traumática ni postquirúrgica así como en ilustrar una localización muy poco frecuente de sangrado asociado a anticoagulación.(AU)

Retrobulbar hemorrhage consists of bleeding in the retroseptal intraorbital region generating an orbital compartment syndrome. We present the case of an 86-year-old woman who came to the Emergency Room due to ocular pain and loss of vision in the left eye of six hours of evolution. The only medical history was atrial fibrillation on anticoagulant treatment with Dabigatran 300mg daily. The clinical examination was compatible with retrobulbar hemorrhage and the urgent CT confirmed the diagnosis, performing immediately after a canthotomy with cantolysis. In the absence of triggering factors, an orbital MRI was performed which ruled out the existence of arteriovenous malformations, diagnosing spontaneous retrobulbar hemorrhage associated with the use of anticoagulants. The uniqueness of this case is that it forms part of the small percentage of retrobulbar hemorrhages that are not associated with trauma or postsurgical causes, as well as in illustrating a very rare location of bleeding associated with anticoagulation.(AU)

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.