32 year old male with history of HTN, presents to your ED complaining of progressive R eye pain and decreased visual acuity after a wooden plank stuck him in the face at work about 2 hours prior. He denies other injuries, denies LOC, denies vomiting, focal neurological deficit, and takes no anticoagulation medications. Vitals normal with GCS 15.
R pupil is sluggishly reactive, 5mm
L pupil reactive to light, 3mm
R eye proptotic
EOMI limited by severe pain
VA: no sensation of light in R eye
Conjunctiva: 360 degree subconjunctival heorrhage
The patient is most likely suffering from orbital compartment syndrome from a traumatic retrobulbar hemorrhage. Due to the risk of progressive, irreversible vision loss, orbital compartment syndrome should be a clinical diagnosis in this case (no need to confirm with imaging prior to intervention).
Ophthalmology is consulted, but cannot get to the hospital for another 2 hours. The patient is at risk of permanent blindness without immediate intervention. Emergent lateral canthotomy is indicated. This is a procedure emergency doctors are expected to know and perform when necessary.
Please follow the link below for details of the procedure:
Pearl: remember to re-assess VA and IOP after the inferior crux is transected. If VA does not improve or IOP remains >40, transection of the superior crux is indicated.