Sight-threatening orbital emphysema treated with needle decompression

Orbital emphysema is rare in the absence of trauma, and is unlikely to result in visual loss. The authors describe a patient with no prior trauma who presented with decreased vision and increased intraocular pressure due to severe orbital emphysema after a sneeze. Computed tomography revealed subcutaneous emphysema of the lid and extraconal air in the orbit. Emergency needle decompression resulted in improvement in vision and intraocular pressure.     

Suck and spit, don't blow: orbital emphysema after decompression surgery.

PURPOSE: To describe the occurrence of vision-threatening orbital emphysema in patients awakening from orbital decompression surgery and to assess risk factors and preventive measures. DESIGN: Small noncomparative case series. PARTICIPANTS: Three patients undergoing bilateral orbital two-wall decompression experienced significant orbital emphysema associated with persistent coughing and Valsalva at the time of extubation. INTERVENTION: In two patients, symptoms resolved with simple observation, whereas one patient required sedation, topical anesthesia around the endotracheal tube, and needle decompression of trapped air. MAIN OUTCOME MEASURES: Visual acuity, pupils, visual fields, and sensorimotor examination. RESULTS: No patient experienced a permanent deficit of visual or sensorimotor function. CONCLUSIONS: Acute orbital emphysema can occur after orbital decompression surgery despite the large bony opening created. Violent coughing spells at the time of extubation are more common in patients with a history of heavy tobacco use and may be causative. Opening the periorbita may be another specific predisposing risk factor. Knowledge of this dangerous phenomenon, along with appropriate perioperative management, may prevent this complication from occurring.     

Severe orbitopalpebral emphysema after nose blowing requiring emergency decompression

PURPOSE: Orbital emphysema is a frequent condition associated with medial wall fractures after blunt trauma. It is usually a benign, self-limited phenomenon. The authors are unaware of previous reports of severe orbital emphysema needing emergency decompression with no evidence of any previous significant trauma such as the case presented herein. METHODS/RESULTS: A 51-year-old woman had painful swelling of the left orbital region that prevented her from opening her eyelids. She complained of a coincident cold with abundant mucous rhinorrhea. She had blown her nose vigorously several times. A computed tomography scan revealed a left proptosis, an extensive orbitopalpebral emphysema, and a blowout fracture of the medial wall of the left orbit. A complete ophthalmic examination was only possible after a needle decompression. No significant ocular damage was observed, so outpatient treatment was provided. Twenty-eight hours later, the swelling had almost disappeared, and the ocular assessment was normal. CONCLUSIONS: A forceful expiratory effort raising intranasal pressure may cause a medial wall orbital fracture. If the airway hyperpressure episodes are repeated, a severe orbitopalpebral emphysema may develop. Should there be any suspicion of vascular compression, it must be drained to allow the assessment of visual function and theoretically prevent a potentially irreversible ischemic visual loss.     

Orbital Compartment Syndrome: The Ophthalmic Surgical Emergency

Orbital compartment syndrome is an uncommon, ophthalmic surgical emergency characterized by an acute rise in orbital pressure. When intraorbital tension rises, damage to ocular and other intraorbital structures, including irreversible blindness, may occur if not promptly treated. The diagnosis of orbital compartment syndrome is completely clinical and early recognition and emergent orbital decompression (even prior to imaging) is essential in preventing permanent vision loss. Lateral canthotomy and inferior cantholysis remain the mainstays of management. More extensive incision of the orbital septum and orbital bony decompression may be necessary in unresponsive cases. This review discusses the various etiologies and mechanisms resulting in orbital compartment syndrome, clinical features, imaging findings, treatment, and prognosis.     

Monocular blindness as a complication of trigeminal radiofrequency rhizotomy

PURPOSE: To raise the awareness of the rare complication of monocular blindness resulting from radiofrequency rhizotomy for trigeminal neuralgia. METHODS: Case series from tertiary referral centers. Patients were referred after complaint of loss of vision. RESULTS: We report three patients who had trigeminal neuralgia and underwent treatment by radiofrequency rhizotomy. Each developed complete loss of vision in one eye immediately after the procedure. One patient died of an unrelated cause, and pathologic analysis revealed changes compatible with acute trauma to the right optic nerve. CONCLUSION: Our third case confirms the hypothesis that traumatic optic neuropathy after trigeminal radiofrequency rhizotomy results from malpositioning of the rhizotomy needle through the inferior orbital fissure into the orbital apex rather than the foramen ovale.     

Acute orbital edema causing reversible blindness after the administration of intravenous contrast agent in a patient with thyroid eye disease

A 55-year-old white woman with severe thyroid eye disease developed marked orbital edema following the administration of intravenous contrast media with complete loss of vision over a 10-minute period while in the radiology waiting room. She was immediately treated with intravenous methylprednisolone with recovery of precontrast visual acuity and resolution of orbital edema. She underwent orbital decompression 2 weeks later and is currently doing well. This potential complication, although rare, should be recognized and treated immediately.     

Acute thyroid eye disease (TED): Principles of medical and surgical management

The active inflammatory phase of thyroid eye disease (TED) is mediated by the innate immune system, and management is aimed at aborting this self-limited period of autoimmune activity. In most patients with TED, ocular and adnexal changes are mild and management involves controlling thyroid dysfunction, cessation of smoking, and addressing ocular surface inflammation and exposure. In patients with acute moderate disease, this being sufficient to impair orbital functions, immunosuppression reduces the long-term sequelae of acute inflammation, and adjunctive fractionated low-dose orbital radiotherapy is used as a steroid-sparing measure. Elective surgery is often required following moderate TED, be it for proptosis, diplopia, lid retraction, or to debulk the eyelid, and this should be delayed until the disease is quiescent, with the patient stable and weaned off all immunosuppression. Thus, surgical intervention during the active phase of moderate disease is rarely indicated, although clinical experience suggests that, where there is significant orbital congestion, early orbital decompression can limit progression to more severe disease. Acute severe TED poses a major risk of irreversible loss of vision due to marked exposure keratopathy, ‘hydraulic'' orbital congestion, or compressive optic neuropathy. If performed promptly, retractor recession with or without a suture tarsorrhaphy protects the ocular surface from severe exposure and, in patients not responding to high-dose corticosteroid treatment, decompression of the deep medial orbital wall and floor can rapidly relieve compressive optic neuropathy, as well as alleviate the inflammatory and congestive features of raised orbital pressure.     

眼眶减压术治疗甲状腺功能障碍性视神经病变

甲状腺功能障碍性视神经病变(dysthyroid optic neuropathy,DON)是甲状腺相关眼病的严重并发症之一。DON由于多病因导致眶内容物增多、眶内压增高,如延误治疗会造成不可逆性视力丧失。及时行眼眶减压术降低眶内压、减弱疾病活动性是治疗DON抢救视力、改善眼突度等的关键。眼眶减压术包括眼眶眶壁去除减压术、眶内脂肪切除减压术等。近年术式有所改进,包括深外侧壁减压术、内外壁平衡减压术、三壁最大化眶减压术、微创硬膜外眼眶减压术、鼻内镜下不同入路眶壁减压术、计算机辅助减压术、多种术式联合减压等,以期得到更好的治疗效果。(国际眼科纵览,2020,44:431-437)     

Treatment of cystic epithelial downgrowth with intralesional administration of mitomycin C

PURPOSE: To report a case of postoperative cystic epithelial downgrowth treated with needle aspiration and intralesional administration of mitomycin C. METHODS: Case report. A 60-year-old woman with a history of right cataract surgery 7 years ago presented with decreased vision of 1/60. The reduced vision was diagnosed secondary to a large acquired cystic epithelial downgrowth on the surface of the iris occluding the pupil. RESULTS: The cystic epithelial downgrowth was treated with aspiration and intralesional administration of mitomycin C solution. There was no evidence of recurrence on follow-up 1 year after the procedure. CONCLUSIONS: Treatment of acquired cystic epithelial downgrowth with needle aspiration and intralesional administration of mitomycin C resulted in a satisfactory outcome without undertaking more extensive and invasive surgical treatments.     

Visual recovery after evacuation of orbital emphysema

Orbital emphysema due to orbital trauma is a well-known occurrence. Visual loss due to orbital emphysema, however, is an uncommon phenomenon. A case of unilateral orbital emphysema following door-handle trauma with subsequent proptosis, painful ophthalmoplegia and compressive optic neuropathy resulting in compromised vision is presented in an 8-year-old male child. Conservative management, including intravenous corticosteroids, failed to resolve the patient's symptoms and compressive optic neuropathy. Surgical intervention to evacuate orbital emphysema resulted in prompt resolution of symptoms, including recovery of vision. A review of the medical literature revealed that only few isolated cases of orbital emphysema with compressive optic neuropathy have been reported previously, with no reports due to door-handle trauma.     

Evolution of an orbital apex tumor over a decade

We report the evolution of an orbital apex tumor that underwent spontaneous regression, followed several years later by rapid growth and loss of vision. A turkey farmer had a right apical lesion, initially thought to be an optic nerve meningioma. The mass spontaneously regressed over 2 years, with marked improvement of vision. Eight years later, the patient presented with loss of light perception and severe proptosis of the right eye from a massive orbital tumor that extended in the cavernous sinus. An eyelid-sparing orbital exenteration was performed. The pathologic diagnosis was diffuse large cell lymphoma. This case demonstrates that non-Hodgkin lymphoma of the orbital apex may resolve spontaneously or it may enlarge rapidly, degenerating into more aggressive forms.     

Central retinal artery occlusion following orbital tumor resection: Is rapid intervention effective?

A 52-year-old male patient presented at our hospital with unilateral proptosis and vision loss in his left eye. Imaging evaluations showed orbital tumor, so the patient underwent surgery. About an hour later after tumor removal, patient developed sudden vision loss and became no light perception. Fundus evaluation revealed central retinal artery occlusion (CRAO). The patient was treated immediately with ocular massage and anterior chamber paracentesis as well as systemic therapy with mannitol and intravenous administration of acetazolamide. After thirty minutes, he recovered perception to light and then hand motion and 2 h later, it was improved to 1 m counting finger. CRAO following orbital tumor has not been reported before. We recommend ocular examination in all patients that undergo orbital surgery immediately to 2–3 h after surgery.     

Complications of fine needle aspiration biopsy of the orbit

When properly used in well-indicated patients, fine needle aspiration biopsy of orbital lesions is an invaluable adjunct diagnostic technique. In experienced hands, the success rates have been high and the complications rare and minor. If the protocols are not followed or the surgeon is inexperienced, serious complications may result. A recent survey among 202 oculoplastic and orbital surgeons, with a total of 152 patients, confirmed this. In 138 patients, the biopsy was performed by an oculoplastic or orbital surgeon, and 10 minor complications were reported. Eleven out of the 14 remaining patients were seen by an oculoplastic or orbital surgeon in consultation for complications arising from a fine needle aspiration biopsy of the orbit performed by someone else. Complications in this group of patients included orbital hemorrhage requiring orbital decompression, motility disturbance, ptosis, and blindness. There were three deaths.     

Orbital decompression for thyroid orbitopathy

Background: Severe thyroid orbitopathy may result in optic neuropathy, corneal exposure and disfiguring proptosis, Orbital decompression has most commonly been performed for optic neuropathy, but with improved techniques, more patients are undergoing decompression for other indications. Purpose: This report evaluates the results and morbidity of orbital decompression for thyroid orbitopathy performed by one surgeon. Methods: The records of 33 patients (53 orbits) undergoing orbital decompression for thyroid orbitopathy were analysed for changes in visual acuity and colour vision (where the indication was optic neuropathy) and reduction in proptosis. Complications were also analysed. Results: Visual acuity and colour vision improved in all 33 eyes with optic neuropathy in the short term postoperative period (4 weeks), but later deteriorated in five eyes (6.6%) of 4 patients (19%). Proptosis decreased by a mean 5.3 mm (range, 1–10). Diplopia developed or worsened overall in 10 of 33 patients (30%), but only in one of 12 (8%) where the indication was cosmesis or corneal exposure. Diplopia improved in 2 of 33 (6%). All patients with symptomatic diplopia achieved binocular single vision in a useful range after one and sometimes two squint procedures. No patient lost vision as a result of surgery. Conclusions: Orbital decompression is effective in improving vision in most patients with thyroid optic neuropathy, but induces or worsens diplopia in a high proportion of these patients. Proptosis can be effectively and dramatically improved.     

Visual Recovery after Evacuation of Orbital Emphysema

Orbital emphysema due to orbital trauma is a well-known occurrence. Visual loss due to orbital emphysema, however, is an uncommon phenomenon. A case of unilateral orbital emphysema following door-handle trauma with subsequent proptosis, painful ophthalmoplegia and compressive optic neuropathy resulting in compromised vision is presented in an 8-year-old male child. Conservative management, including intravenous corticosteroids, failed to resolve the patient's symptoms and compressive optic neuropathy. Surgical intervention to evacuate orbital emphysema resulted in prompt resolution of symptoms, including recovery of vision. A review of the medical literature revealed that only few isolated cases of orbital emphysema with compressive optic neuropathy have been reported previously, with no reports due to door-handle trauma.     

Orbital decompression for Grave's disease leaving the periosteum intact

A prospective trial was carried out to determine whether or not transorbital floor and medial wall decompression without opening the orbital periosteum would relieve compressive optic neuropathy in patients with Grave's disease. In four orbits (three patients), the procedure was performed, and in all cases, the vision returned to 20/30 or better. All other parameters of optic nerve function improved as well. No patient had worsening of ocular motility that was attributable to the surgery. The amount of retroplacement of the globe may be less than with standard orbital decompression.     

Fine needle aspiration biopsy in the diagnosis of intraocular cancer. Cytologic-histologic correlations

Fine needle aspiration biopsy was used as an investigational procedure in the evaluation of 71 eyes harboring a suspected intraocular malignancy between January 8, 1981, and January 21, 1983. Twenty-seven of these 71 biopsies were performed prior to any treatment as a diagnostic procedure and the others were performed following enucleation or tumor excision to provide specimens for cytologic-histologic correlation. The histologic findings confirmed the cytologic diagnosis of malignancy or benignancy in 94.3% of the 53 cases in which a corresponding tissue specimen was available for histologic evaluation. None of the eight eyes with a cytologically confirmed diagnosis of malignancy that were managed conservatively following the biopsy has experienced visual loss attributable to the biopsy. There have been no instances of documented needle tract seeding by tumor cells or orbital tumor recurrence to date in the 27 cases in which diagnostic fine needle aspiration biopsy had been performed prior to treatment.     

Orbital melanoma masquerading as a “Galloping haemangioma”

We describe a 32-year-old pregnant woman who was referred to our clinic after 6 weeks of observation elsewhere with a rapidly expanding orbital mass, proptosed globe and slowly decreasing of vision in her left eye. To our examination the patient presented with congested optic disc fine macular striae and some slight choroidal elevation without any retinal pigmentation. An MRI scan without contrast was performed, suggesting the signal charactheristics of an orbital mass consistent with a cellular lesion such as a cavernous hemangioma or a solitary fibrous tumour. Despite the benign-looking imaging, the fast-growing pattern of the lesion suggested a more sinister picture. A fine needle aspiration of the orbital mass was carried out, revealing the presence of an amelanotic melanoma. This case highlights the importance of considering the presence of a melanoma when there is a clear history of a rapid lesion progression.     

Results of a neurosurgical two-wall orbital decompression in the treatment of severe thyroid associated ophthalmopathy

PURPOSE: Follow-up of patients with severe thyroid associated ophthalmopathy treated with a transcranial two-wall orbital decompression and reconstruction. METHODS: A two-wall transcranial orbital decompression was performed in 30 such patients (50 eyes). The patients were evaluated one month postoperatively, and long-term evaluation (median 14 months, range 2-54 months) was carried out. The main outcome measures were visual acuity, proptosis measured by Hertel ophthalmometry, soft tissue involvement, and restriction of eye motility. RESULT: Visual acuity improved rapidly in 28 of 32 affected eyes with normalization in 19 eyes (p<0.001). Worsening was not seen. Median proptosis was reduced by 4.0 mm, range 0-10.0 (p<0.001). Double vision was present in 24 patients before operation 14 of whom achieved binocular vision (p<0.001). Three patients had unchanged complaints and the double vision worsened in one patient. Seventeen of 20 patients on preoperative corticosteroid treatment discontinued this medication in relation to surgery. Complications included one case of perioperative minor stroke and two cases of facial nerve frontal branch palsy. CONCLUSION: The transcranial two-wall decompression is a simple, an efficient and a low-risk procedure for treatment of patients with severe thyroid associated ophthalmopathy.     

Orbital Emphysema As An Ophthalmologic Emergency

Orbital emphysema is generally a benign, self-limited condition. However, if a fracture produces a ball-valve effect allowing air to enter but not to leave the orbit, and if the orbital septum remains intact, then extremely high intraorbital pressure and visual loss is possible. Two cases are described of visual loss from orbital emphysema, in a 33-year-old man and a 28-yearold man, which were successfully treated by a lateral canthotomy and cantholysis.