Other causes of OCS include orbital congestion secondary to burn resuscitation and significant orbital emphysema after orbital fracture (pneumo-orbita). OCS from any cause may have a delayed onset. Patients with trauma to the orbit must be closely monitored for development of OCS.

Goal

Lower the orbital compartment pressure as soon as possible to prevent tissue damage.

Minimum

- Prompt recognition of injury and identification of the need for intervention
- History of trauma with any of the following findings:
  - Proptosis: bulging of the affected eye compared with the other eye; proptosis in RBH is often tense and painful
  - Increased orbital pressure around the eye or IOP by palpation (increased firmness and resistance compared with opposite eye)
  - Decrease in or loss of visual acuity
  - Presence of an RAPD (Appendix A)
- Raise head 30°–45°.
- Initiate pain control as needed.
- Initiate antiemetic (ondansetron 4mg ODT/IV/IO/IM every 8 hours as needed).
- Perform lateral canthotomy/cantholysis (LCC) as soon as possible, within 90 minutes of injury if evacuation to a surgical capability is anticipated to take more than 60 minutes.
- Activate evacuation with goal of evaluation by an eye surgeon within 24 hours.

Initiate teleconsultation with photographs.

Better

- Minimize patient movements; maintain supine position with head at 30°–45°.
- Ice packs and avoidance of compressive dressings7
- Monitor for return of elevated orbital pressure.

Best

- Initiate a detailed ocular evaluation and continue monitoring IOP, vision, and RAPD.
- Continue to check for recurrence of elevated IOP even after LCC. If the vision deteriorates and the eye again becomes firm after LCC, this may signify rebleeding in the orbit. Evacuation of orbital hemorrhage is not feasible in a PFC environment and rebleeding will require medical treatment.8
  - Acetazolamide: 500mg PO initial dose, followed by 250mg PO 4 times per day (Note: contraindicated in patients with sickle cell trait)
  - If acetazolamide is not available or if the patient cannot take PO, either 3% hypertonic saline 250mL IV or mannitol: 1g/kg IV over 30–60 minutes can be used to decrease IOP.9
  - Corticosteroid: 1g methylprednisolone IV once 10
  - Initiate real-time video telemedicine consultation.
  - No altitude restrictions are required for evacuation.

NOTES:

- LCC is a vision-saving procedure with minimal risk of causing additional ocular injury. When in doubt, perform the LCC immediately.

In thermal burns, consider early LCC (before full OCS develops). Fluid resuscitation requirements will take precedence over the use of medical treatments to reduce IOP.

3. BLUNT / CLOSED GLOBE INJURY

This category includes anterior segment injuries such as hyphema (bleeding into the anterior chamber) and posterior segment injuries such as vitreous hemorrhage and retinal detachment. Blunt trauma can result in severe loss of vision.