Today on the podcast, we discuss orbital compartment syndrome, a new method of decompression, and other tips and tricks for this eye emergency.
Our Guest
Dr. Julia T. Elpers is a board-certified ophthalmologist specializing in ophthalmic plastic and reconstructive surgery. A Louisville native, she completed her undergraduate degree with honors in Biology, with minors in Fine Art and Chemistry, at Bellarmine University in Louisville, KY. She obtained her Doctor of Medicine at the University of Kentucky College of Medicine. She then completed her internship at Methodist Hospital in Indianapolis before returning to Kentucky to complete both her residency in Ophthalmology & Visual Sciences and a two-year fellowship in Ophthalmic Plastic and Reconstructive Surgery at the University of Louisville.
Indications for Decompression
Intraocular Pressure >= 40 mmHg needs decompression (probably anything int he high 30's or with significant discrepancy from the unaffected eye)
Visual Acuity
Afferent Pupillary Defect (APD)
Proptosis
Contraindications
None if vision is at threat
Tests for Optic Nerve Compression
Red Saturation Test
Swinging Flashlight for Afferent Pupillary Defect (APD)
Steps from Broadway DC [PMID: 23520419]
-
Use a bright torch which can be focussed to give a narrow, even beam of light. Perform the test in a semi-darkened room. If the room is too dark it will be difficult to observe the pupil responses, particularly in heavily pigmented eyes.
-
Ask the patient to look at a distant object, and to keep looking at it. Use a Snellen chart, or a picture. This is to prevent the near-pupil response (a constriction in pupil size when moving focus from a distant to a near object). While performing the test, take care not to get in the way of the fixation target.
-
Move the whole torch deliberately from side to side so that the beam of light is directed directly into each eye. Do not swing the beam from side to side around a central axis (e.g. by holding it in front of the person's nose) as this can also stimulate the near response.
-
Keep the light source at the same distance from each eye to ensure that the light stimulus is equally bright in both.
-
Keep the beam of light steadily on the first eye for at least 3 seconds. This allows the pupil size to stabilise. Note whether the pupil of the eye being illuminated reacts briskly and constricts fully to the light. Also note what happens to the pupil of the other eye: does it also constrict briskly?
-
Move the light quickly to shine in the other eye. Again, hold the light steady for 3 seconds. Note whether the pupil being illuminated stays the same size, or whether it gets bigger. Note also what happens to the other eye.
-
As there is a lot to look at, repeat the test, observing what happens to the pupils of both eyes when one and then the other eye is illuminated.
When the test is performed on someone with unilateral optic nerve compression, a RAPD should be present, The following happens:
-
When the light is shone into the eye with the retinal or optic nerve disease, the pupils of both eyes will constrict, but not fully. This is because of a problem with the afferent pathway.
-
When the light is shone into the other, normal (less abnormal) eye, both pupils will constrict further. This is because the afferent pathway of this eye is intact, or less damaged than that of the other eye.
-
When the light is shone back into the abnormal eye, both pupils will get larger, even the pupil in the normal eye.
-
It doesn't matter whether you start with the eye you think has the greater problem or the healthier eye: as long as the light is switched from one eye to the other and back again the signs should become apparent.
POCUS Swinging Flashlight Test for APD
How to Perform POCUS Test for APD
Paracanthal “One Snip” Method and the Vertical Lid Split
Procedure
Anesthesia?
1 ml in each lid with a small needle directed away from the eye
References
Blandford, Alexander D., Jason M. Young, Sruthi Arepalli, Ang Li, Catherine J. Hwang, and Julian D. Perry. “Paracanthal ‘One-Snip’ Decompression in a Cadaver Model of Retrobulbar Hemorrhage.” Ophthalmic Plastic and Reconstructive Surgery 34, no. 5 (2018): 428–31. https://doi.org/10.1097/IOP.0000000000001032.
Yarter, Jason T., Justin Racht, and Kevin S. Michels. “Retrobulbar Hemorrhage Decompression with Paracanthal ‘One-Snip’ Method: Time to Retire Lateral Canthotomy?” The American Journal of Emergency Medicine 64 (February 2023): 206.e1-206.e3. https://doi.org/10.1016/j.ajem.2022.11.027.
Lateral Canthotomy and Cantholysis
Lateral Canthotomy/Lysis Review
Larry Mellick's Video is Superb
Additional Information
- Justin at First10EM did a post on this as well
- EMCurious' Post
- Retrobulbar Hemorrhage Options
More on EMCrit
You Need an EMCrit Membership to see this content. Login here if you already have one.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 389 – Massive Transfusion Update and Hemostatic Resuscitation - December 1, 2024
- EMCrit 388 – Experts' Guide to the Bougie with Barnicle and Driver - November 22, 2024
- EMCrit RACC Lit Review – October/November 2024 - November 7, 2024
For either of these procedures, how often does the pressure rebound if the retrobulbar bleeding persists?
in my limited experience, when a proper release is performed, the pressure doesn’t rebound as there is now a path for the blood to exit.
I am just a medical student with a background as an EM PA, but my wife is an ENT and I discussed this podcast with her. As someone who has done a few lateral canthotomies with cantholysis and more than her fair share of orbital trauma, she took offence with the statement that repair of the tarsal plate is no more difficult than the repair of the canthal tendon. Apparently it is much easier to achieve appropriate suspension of the globe and good closure of the lid if you just need to repair the tendon. Her argument was that the… Read more »
So it seems we have an oculoplastic surgeon saying one thing and an Ear Nose and Throat surgeon saying something contrary. How would you reconcile this disagreement?
I prob just overlooked it but where is the description of the red light APD test?
-Sean
Just look under the heading of Red Saturation Test Above
How often does the pressure go back up after either of these treatments if the retrobulbar bleeding doesn’t go away? driving directions