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Findings

• Accumulation of air in the orbit and/or eyelids
  • Typically after medial orbital wall fracture followed by nose blowing
• Swelling of the eyelids
• Palpable crepitation
• Proptosis, visual impairment, double vision (often when looking upward), increased intraocular pressure, lagophthalmos
• Warning signs: Pain, visual impairment, relative afferent pupillary defect (RAPD), increased intraocular pressure, restricted motility

Work-up

• Clinical examination, visual acuity, intraocular pressure (IOP), motility, RAPD.
• Head CT

Treatment

• Mostly observational as it is self-limiting
• Oral antibiotics (e.g., Co-Amoxicillin 625mg 3x/day for 7-10 days)
• Decongestant nasal spray (e.g., Otrivin 0.1% 2x/day)
• Local cooling, elevated upper body, avoid nose blowing!
• If suspected orbital compartment syndrome (Stages (II), III-IV):
  • Air aspiration with a needle for orbital decompression
  • consider high dose corticosteroid therapy
  • +/- lateral canthotomy and cantholysis
  • +/- bone decompression

Stages

• I: radiological, no clinical sign
  • conservative
• II: globe dystopia / proptosis, displacement of the globe horizontally or vertically
  • conservative, except if significant discomfort
• III: Loss of vision due to optic nerve compression, IOP elevated
  • immediate decompression
• IV: Central retinal artery occlusion
  • immediate decompression

Sources

• Wikipedia – Orbital emphysema
• Lin, Che-Yu et al. “Needle decompression in a patient with vision-threatening orbital emphysema.” Taiwan journal of ophthalmology vol. 6,2 (2016): 93-95. doi:10.1016/j.tjo.2015.02.003
• Abdul Shameer et al; Emergency Decompression of Orbital Emphysema with Elevated Intraorbital Pressure; The Journal of Emergency Medicine, Volume 53, Issue 3, 2017, 405-407, https://doi.org/10.1016/j.jemermed.2016.10.021.
• John H. Hunts et. al; Orbital Emphysema: Staging and Acute Management; Ophthalmology, Volume 101, Issue 5, 1994, 960-966, https://doi.org/10.1016/S0161-6420(94)31230-9