4.1 Patient History Leading to the Specific Problem

The patient is a 59-year-old white woman who presented with a history of left posterior orbital mass of undiagnosed etiology, referred for biopsy with the oculoplastics service. Preoperative vision in the left eye was 20/25 and extraocular movements were full. A left orbitotomy was performed under general anesthesia, and specimens of soft tissue and bone were obtained. The remainder of the surgical case was uneventful. During initiation of awakening from general anesthesia, the patient was witnessed to have a significant gag reflex with Valsalva. She subsequently developed immediate clinical signs of left retrobulbar hemorrhage including tense periorbital ecchymoses and 360° bullous subconjunctival hemorrhage (Fig. 4-1).

4.2 Anatomic Description of the Patient’s Current Status

Hemorrhage in the retrobulbar space may lead to a compartment syndrome as the hematoma fills the rigid bony orbit and pushes the globe anteriorly (proptosis) to the maximum extent the eyelids will allow. Further hemorrhage within the confined space of the orbit will then compress the orbital contents, which may rapidly lead to an ischemic optic neuropathy, central retinal artery occlusion, or central retinal vein occlusion, all of which may cause permanent vision loss.

4.3 Recommended Solution to the Problem

Immediately release sutures closing the incision in order to reopen the orbital compartment and relieve intracompartmental pressure.

If this is insufficient to relieve the compartment syndrome, perform a lateral canthotomy with inferior cantholysis, with additional superior cantholysis as needed.

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  Re-establish general anesthesia.

  
  
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  Explore the surgical wound to identify source of hemorrhage.

  
  
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  Obtain hemostasis.

  
  
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  Consider replacing incision closure only if the eyelids are soft and mobile and concern for redevelopment of orbital compartment syndrome is low.

  
  
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  If the patient presents postoperatively with a retrobulbar hemorrhage and orbital compartment syndrome, perform a lateral canthotomy and cantholysis to relieve the intraorbital pressure.

4.4 Technique

The Prolene sutures closing the skin incision, the Vicryl sutures closing orbicularis muscle, and the Vicryl sutures closing the periosteum were immediately cut and released. With release of the previously placed sutures, the periorbital tissues became less tense and the eyelids became more freely mobile over the globe. General anesthesia was resumed and the patient was reprepped in the standard fashion for oculoplastic surgery. The surgical wound was explored and the source of bleeding was identified. Hemostasis was achieved with a combination of bipolar cautery and Avitene. Closure of the periosteum, orbicularis, and skin was replaced.

In alternative presentations, retrobulbar hemorrhage causing a compartment syndrome may be addressed with a canthotomy and cantholysis at the lateral canthus, the outer angle of the eyelids (Fig. 4-2). One may consider cleaning the surgical site and injecting local anesthetic to the subcutaneous tissue of the lateral canthus; however, these steps may be bypassed in certain scenarios given the emergent nature of the problem.

The lateral canthotomy is performed using the available scissors to cut horizontally from the angle of the lateral canthus to the lateral orbital rim, approximately 1 cm (Fig. 4-3).

Grasp the lower lid laterally with toothed forceps and distract the lid away from the globe—it will still feel tethered in place due to the attachment of the inferior crus of the lateral canthal tendon (Fig. 4-4).

Use the closed blades of the scissors to strum the tissue still tethering the lateral lower lid to the orbital rim near the globe—this represents the inferior crus of the lateral canthal tendon which should be cut (Fig. 4-5).

Once the inferior crus is identified, inferior cantholysis is performed by an approximately 1-cm cut from the cut edge of the lower lid in an inferoposterior direction (Fig. 4-6).

Upon successful inferior cantholysis, the lower lid should be freely mobile and no longer adherent to the orbital rim (Fig. 4-7).

At this point, if the upper lid is noted to be tense and tight against the globe and there remains concern for an orbital compartment syndrome, a superior cantholysis may be performed. Grasp the upper lid laterally with toothed forceps and distract the lid away from the globe. Use the closed blades of the scissors to strum the superior crus which tethers the lateral upper lid to the orbital rim. Superior cantholysis is performed by an approximately 1-cm cut from the cut edge of the upper lid in a superoposterior direction. Upon successful superior cantholysis, the upper lid should be freely mobile and no longer adherent to the orbital rim.