Orbital Emphysema

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  • 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


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


  • 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


  • 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


  • 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
  • Shameer A, Pushker N, Lokdarshi G, Basheer S, Bajaj MS. Emergency Decompression of Orbital Emphysema with Elevated Intraorbital Pressure. J Emerg Med. 2017 Sep;53(3):405-407. doi: 10.1016/j.jemermed.2016.10.021. PMID: 28992871.
  • Hunts JH, Patrinely JR, Holds JB, Anderson RL. Orbital emphysema. Staging and acute management. Ophthalmology. 1994 May;101(5):960-6. PMID: 8190488.