A 27-year-old man presents to the emergency department after a bar fight. He was punched in the eye and is having pain and blurry vision. The patient is otherwise healthy and does not take any medications. His temperature is 98.1°F (36.7°C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for conjunctival injection of the patient’s left eye as shown in Figure A. Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left. His left pupil is sluggish to constrict when compared to the right. A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye. Which of the following is the most appropriate next step in management?
Lateral canthotomy
Cyclopentolate
Topical timolol and pilocarpine
Orbital ultrasound
Lateral canthotomy
This patient is presenting after blunt trauma to the eye with eye pain, blurry vision, conjunctival injection, a sluggish pupil, and elevated intraocular pressure (> 20 mmHg) suggesting a diagnosis of a retrobulbar hematoma/hemorrhage causing orbital compartment syndrome. The most important initial step in management is a lateral canthotomy to alleviate retrobulbar pressure.

A retrobulbar hematoma (or hemorrhage) occurs after blunt trauma to the eye. Presenting symptoms may include eye pain, photophobia, proptosis (an eye that appears to be anteriorly displaced), decreased visual acuity, and conjunctival injection. It is important to perform a thorough exam including a slit lamp exam and a fluorescein stain to rule out other traumatic injuries such as a globe rupture. Tonometry can be used to assess for increased intraocular pressure. A pressure > 20 mmHg suggests a diagnosis of orbital compartment syndrome, a vision-threatening condition. Immediate management with a lateral canthotomy is indicated in order to relieve pressure on the optic nerve and retina and save the patient’s vision. Further management may require drainage of the hematoma in the operating room.

Burkat et al. review the technique for performing a lateral canthotomy to relieve pressure in retrobulbar hematoma. The authors first excise the skin and orbicularis muscle at the lateral canthal angle in a horizontal direction for approximately 10 mm. The authors then recommend performing an inferior cantholysis by incising the inferior crus (a thick fibrous band connecting the lateral lower eyelid to the orbital rim) near the orbital rim.

Figure A demonstrates proptosis on physical exam which raises concern for a retrobulbar hematoma that is likely increasing orbital compartment pressure.

Incorrect Answers:
Answer A: CT scan of the head and facial bones would be appropriate if there was a concern for facial fracture. It would delay necessary and vision-saving interventions to perform a CT scan in the setting of orbital compartment syndrome. However, cross-sectional imaging may be performed after the pressure is relieved.

Answer B: Cyclopentolate is a cycloplegic that can be used to reduce pain in traumatic iritis. This typically presents after blunt trauma to the eye with erythema, photophobia, blurry vision, and cell/flare in the anterior chamber on slit lamp exam. A sluggish pupil may also be seen; however, increased intraocular pressure would not be seen in this condition.

Answer D: Orbital ultrasound could be used for diagnoses such as a retinal detachment which presents with flashes of light, floaters, and visual field loss like a “curtain coming down over the eye.” An ultrasound would demonstrate the detached retina in the back of the eye. Management involves elevating the head of the bed and surgical reattachment.

Answer E: Topical timolol and pilocarpine in addition to brimonidine, acetazolamide, and possible iridotomy would be the appropriate management of acute closed-angle glaucoma which presents with a rock-hard eye, blurry vision, a mid-dilated and fixed pupil, as well as a headache. This diagnosis can be supported by elevated intraocular pressure on tonometry. This is unlikely for this patient in the context of trauma.

Bullet Summary:
A retroorbital hematoma can cause orbital compartment syndrome which requires immediate treatment with a lateral canthotomy.