FIGURE 3 - uploaded by Rohan Mangal
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CT demonstrating right exophthalmos (arrow) with intraorbital fat stranding and abnormal caliber and density of the optic nerve sheath complex. Also seen is right preseptal subcutaneous soft tissue swelling and hematoma.
Source publication
In the following case presentation, a young man who incurred orbital compartment syndrome (OCS) from physical trauma significantly improved from timely lateral canthotomy. Lateral canthotomy is recommended to be performed as soon as possible to avoid permanent vision loss, which is the most feared complication associated with orbital compartment sy...
Contexts in source publication
Context 1
... Tomography (CT) scan of the head, orbits, and maxillofacial bones were obtained which revealed right exophthalmos with intraorbital fat stranding and abnormal caliber and density of the optic nerve sheath ( Figure 3). The decision was made to transfer the patient to our facility for ophthalmology evaluation. ...
Context 2
... Tomography (CT) scan of the head, orbits, and maxillofacial bones were obtained which revealed right exophthalmos with intraorbital fat stranding and abnormal caliber and density of the optic nerve sheath ( Figure 3). The decision was made to transfer the patient to our facility for ophthalmology evaluation. ...
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Citations
... An IOP for 60 to 100 minutes causes permanent vision loss. 2,8,9 Emergency decompression should be performed if IOP > 40 mmHg. [2][3][4]10,11 The treatment of acute OCS is lateral canthotomy (LTC) and cantholysis (LC) of the inferior crura of the lateral canthal ligament. ...
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.
... The DoD clinical readiness program specifies that periodic assessment and retraining must be performed to assure the capabilities of expeditionary clinical personnel (including general surgeons and emergency medicine physicians) with the potential to be deployed to far-forward units to be able to perform specific procedures, including lateral canthotomy and cantholysis. [12][13][14][15] This discrepancy presented the significant problem to be considered and identified two primary needs: (1) to determine the current capabilities to perform LC/C by military physicians and surgeons who are deployable to far-forward care units and (2) to evaluate the outcomes to determine how best to address the capability gaps. 16 The first purpose of this study was to examine the baseline capabilities of a broad sample of military emergency medicine physicians, general surgeons, and subspecialty ophthalmological surgeons to accurately and independently perform the lateral canthotomy and cantholysis procedures. ...
... [1][2][3][4][5][6][7][8] Apart from ophthalmologists and facial trauma surgeons, military clinical personnel are rarely trained to recognize OCS and perform LC/C, even though these capabilities are designated as critical competencies for clinical readiness. 10,12,13 The challenge presented by their respective, current expeditionary scope of practice is significant for general surgeons and emergency medicine physicians, both of which are deployable to farforward units (roles 1 and 2). The outcomes from this study demonstrate that ophthalmologists were able to meet the performance standards for LC/C without additional professional development. ...
Introduction
Preservation of life, preservation of limb, and preservation of eyesight are the priorities for military medical personnel when attending to casualties. The incidences of eye injuries in modern warfare have increased significantly, despite personal eye equipment for service members. Serious eye injuries are often overlooked or discovered in a delayed fashion because they accompany other life- and limb-threatening injuries, which are assigned a higher priority. Prehospital military ocular trauma care is to shield the eye and evacuate the casualty to definitive ophthalmic care as soon as possible, with exceptions for treatment of ocular chemical injury and orbital compartment syndrome. Retrospective analysis of eye injuries in recent conflicts identified gaps in clinical capabilities with up to 96% of ocular injuries being suboptimally managed. Ocular compartment syndrome (OCS) is a complication associated with orbital hemorrhage, where significant morbidity occurs as a result of increasing intracompartment pressure. The ischemic tolerance of the retina and optic nerve is approximately 90 minutes, so OCS must be rapidly diagnosed and aggressively treated through lateral canthotomy/cantholysis (LC/C) to prevent permanent vision loss. LC/C procedures consist of using hemostats to crush the lateral canthal fold and cutting the lateral canthal tendon from the inferior crus to relieve increasing intracompartment pressure. The purpose of this study was to examine the baseline capabilities of military physicians and surgeons to accurately and independently perform the LC/C procedures and identify performance gaps that could be closed through focused professional development activities.
Materials and Methods
This study received institutional review board approval at our institution. A total of 60 subjects voluntarily participated in the study from emergency medicine (15), general surgery (28), and ophthalmology (17). All procedural assessments were performed 1:1 by expert faculty ocular trauma specialists using a high-reliability eye trauma simulator (Sonalysts, Inc.). The competency standard was set at independent and accurate completion of all procedural components and all critical procedural components. Analyses were performed using descriptive statistics and analysis of variance to examine between-group differences (P < 0.05).
Results
There was a significant difference between the total score performance and the critical score performance for the three groups (P < 0.001). Outcomes indicate a significant linear relationship between the expertise level of the clinical provider and the procedural performance of LC/C. Outcomes demonstrate the baseline surgical capabilities of the general surgeons transferred to LC/C performance; however, they were unfamiliar with the anatomy and the procedural techniques and requirements. The group of emergency medicine participants demonstrated performance gaps not only in the same areas as the general surgeons but also in their baseline surgical abilities. This suggests that different professional development activities are necessary for surgeons and physicians tasked with performing LC/V procedures.
Conclusions
We identified significant performance gaps among emergency medicine physicians, general surgeons, and ophthalmologists in their abilities to recognize and treat OCS through LC/C procedures. These sight-saving procedures are a critical competency for forward-situated clinicians in expeditionary contexts. We identified the need for targeted approaches to professional development for closing the performance gaps for both emergency medicine physicians and general surgeons.
Zusammenfassung
Die Diagnostik und Therapie von Erkrankungen der Orbita ist eine interdisziplinäre Aufgabe, an der u.a. die Fachdisziplinen HNO-Heilkunde, Augenheilkunde, Radiologie, Strahlentherapie, MKG-Chirurgie, Endokrinologie und Pädiatrie beteiligt sind. Der vorliegende Übersichtsartikel stellt eine Zusammenstellung der häufigsten Erkrankungen dar, mit denen die Fachdisziplinen HNO-Heilkunde und Augenheilkunde interdisziplinär befasst sind. Es werden die akuten entzündlichen Erkrankungen incl. orbitaler Komplikationen, die autoimmunologischen Erkrankungen der Orbita incl. der endokrinen Orbitopathie, und die tumorösen Erkrankungen besprochen. Neben der Diagnostik und der Beschreibung der Klinik wird besonderes Augenmerk auf die interdisziplinäre Therapie gelegt. Abgerundet wird der Übersichtsartikel mit der Beschreibung der wichtigsten chirurgischen Zugangswege zur Orbita, ihre Indikationen und mögliche Komplikationen. Die Autoren haben versucht, trotz der knappen Darstellung die relevanten Fakten zu beschreiben.
A woman, 19 years old, with a history of falling from a height with resulting zygomatico-maxillar complex fracture on the right side, a mandibular fracture on the left side for which she underwent repair with plate insertion, and traumatic optic atrophy in her right eye, presented 9 months later with eye facial swelling, proptosis, and acute rapid loss of vision in the left eye. The diagnosis was done immediately aided by radiology assistance and a decision was taken to admit the patient to undergo urgent decompression to save the vision and the patient did recover well. This case presented here and the associated literature review focus on severe orbital emphysema with compressive optic neuropathy and orbital compartment syndrome as a morbidity that can exist with delayed presentation after trauma and not elicited by sneezing or forced blowing, as well as the drastic importance of brisk intervention, to save vision and prevent visual complications if left untreated.
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.
