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Vision-Threatening Massive Orbital Emphysema After Infero-Medial Orbital Decompression Associated With Sneezing Antonio Augusto V. Cruz, M.D.*†‡, Patricia M. S. Akaishi, M.D.*†§, Alicia Galindo†, and Mohammed Al-Dufaileej, M.D.† *School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil; †King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; and ‡Wilmer Institute, Johns Hopkins University (EUA), Baltimore, Maryland, U.S.A; §Department of Ophthalmology, Complejo Asistencial Palencia, Palencia, Spain.
FIG. 1. Top, Massive conjunctival air ballooning. Bottom, Coronal (left) and axial (right) CT scans showing diffuse air infiltration into the left orbit. A small bone defect can be seen on the infero-medial wall communicating the orbit with the nose cavity.
FIG. 2. Before and after air–needle aspiration, cantholysis, and nose packing.
O
rbital emphysema is a well-known cause of orbital compartment syndrome. A literature review (165 articles) shows that air can enter the orbit in a large variety of situations including fractures, surgeries (neuro, retinal, thoracic, nose, sinus, and dental procedures), violent Valsalva maneuvers (such as during weight lifting, nose blowing, sneezing), accidents with highly compressed air, self-inflicted injuries (Munchausen syndrome), infections, atmospheric pressure changes, and sinus Accepted for publication November 29, 2014. The authors have no financial or other conflicts of interest to disclose. Address correspondence and reprint requests to Antonio Augusto V. Cruz, Hospital das Clínicas-Campus, Ribeirão Preto 14049-900, São Paulo, Brazil. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000393
Ophthal Plast Reconstr Surg, Vol. 31, No. 5, 2015
diseases. For most of the cases, the causative mechanism is due to a bony defect on the medial or inferomedial orbital wall. However, it is curious to notice that orbital emphysema is a rare complication of orbital decompression despite removal of large portions of these walls. We are aware of just 4 patients who had orbital emphysema right after inferomedial decompression. Figure 1 shows a Saudi male patient with Graves orbitopathy who developed massive orbital emphysema on the fifth postoperative day after an uneventful transconjunctival inferomedial decompression. The patient had allergic rhinitis, and the emphysema appeared after a severe episode of sneezing. The preoperative visual acuity, which was 20/30 OU had dropped in the affected eye to 20/800. The impressive emphysema was successfully reduced with cantholysis, air–needle aspiration, and nasal packing with full recovery of the visual acuity (Fig. 2).
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Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
Vision-Threatening Massive Orbital Emphysema After Infero-Medial Orbital Decompression Associated With Sneezing Antonio Augusto V. Cruz, M.D.*†‡, Patricia M. S. Akaishi, M.D.*†§, Alicia Galindo†, and Mohammed Al-Dufaileej, M.D.† *School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil; †King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia; and ‡Wilmer Institute, Johns Hopkins University (EUA), Baltimore, Maryland, U.S.A; §Department of Ophthalmology, Complejo Asistencial Palencia, Palencia, Spain.
FIG. 1. Top, Massive conjunctival air ballooning. Bottom, Coronal (left) and axial (right) CT scans showing diffuse air infiltration into the left orbit. A small bone defect can be seen on the infero-medial wall communicating the orbit with the nose cavity.
FIG. 2. Before and after air–needle aspiration, cantholysis, and nose packing.
O
rbital emphysema is a well-known cause of orbital compartment syndrome. A literature review (165 articles) shows that air can enter the orbit in a large variety of situations including fractures, surgeries (neuro, retinal, thoracic, nose, sinus, and dental procedures), violent Valsalva maneuvers (such as during weight lifting, nose blowing, sneezing), accidents with highly compressed air, self-inflicted injuries (Munchausen syndrome), infections, atmospheric pressure changes, and sinus Accepted for publication November 29, 2014. The authors have no financial or other conflicts of interest to disclose. Address correspondence and reprint requests to Antonio Augusto V. Cruz, Hospital das Clínicas-Campus, Ribeirão Preto 14049-900, São Paulo, Brazil. E-mail: [email protected] DOI: 10.1097/IOP.0000000000000393
Ophthal Plast Reconstr Surg, Vol. 31, No. 5, 2015
diseases. For most of the cases, the causative mechanism is due to a bony defect on the medial or inferomedial orbital wall. However, it is curious to notice that orbital emphysema is a rare complication of orbital decompression despite removal of large portions of these walls. We are aware of just 4 patients who had orbital emphysema right after inferomedial decompression. Figure 1 shows a Saudi male patient with Graves orbitopathy who developed massive orbital emphysema on the fifth postoperative day after an uneventful transconjunctival inferomedial decompression. The patient had allergic rhinitis, and the emphysema appeared after a severe episode of sneezing. The preoperative visual acuity, which was 20/30 OU had dropped in the affected eye to 20/800. The impressive emphysema was successfully reduced with cantholysis, air–needle aspiration, and nasal packing with full recovery of the visual acuity (Fig. 2).
e139
Copyright © 2015 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
