Surgical trauma to the orbit

The orbital contents may occasionally be damaged due to inadvertent entry into the orbit during endoscopic sinus surgery and may result in devastating complications, such as severe motility restriction or blindness (Figure 14.13). Direct damage to the orbital fat, muscles and, more rarely, optic nerve, may occur, especially during power-assisted debridement of diseased sinus tissues. The most important point in the management of inadvertent orbital entry is recognition and immediate cessation of further surgery; in particular the orbit should be observed for signs of traction on the orbital tissues and for small movements of the globe.

Injury to the ethmoidal arteries may result in orbital haemorrhage with compressive optic neuropathy and this may require anterior orbitotomy, drainage of the haematoma and diathermy of damaged vessels.

Orbital haemorrhage more commonly follows orbital surgery or after retrobulbar or peribulbar injections for intraocular and periocular surgery; it may also occur with blepharoplasty, when it is thought to arise from

Figure 14.13 Blindness and gross right exotropia after avulsion of the right medial rectus, inferior oblique and optic nerve during endoscopic sinus surgery.

traction damage to small deep orbital vessels. A venous bleed is of slower onset and will usually self tamponade with vision frequently recovering. Firm orbital pressure may assist tamponade and a lateral cantholysis after 5-10 minutes may assist reduction in intraorbital pressure after tamponade has occurred.

A rapid development of proptosis is likely to be arterial bleeding and should be dealt with by very firm orbital pressure applied for about 8-10 minutes, but being released for about 15 seconds every 2 minutes to allow ocular perfusion. If the orbital pressure rises to a very high level, with loss of eye movements and vision not attributable to local anaesthesia, then the orbit should be drained through a skin incision in the affected quadrant; once the skin is opened, a closed pair of blunt-ended scissors should be gently advanced about 3cm into the orbital fat of the affected quadrant and the blades gently opened to spread the tissues and encourage drainage of blood and tissue fluid. This manoeuvre is generally sufficient to release the orbital tamponade, with restoration of vision, and a drain should be placed until the bleeding has stopped.

Further reading

Anderson RL, Panje WR, Gross CE. Optic nerve blindness following blunt forehead trauma. Ophthalmology 1982; 89:445-55.

Baker RS, Epstein AD. Ocular motor abnormalities from head trauma. Surv Ophthalmol 1991; 35:245-67. Biesman BS, Hornblass A, Lisman R, Kazlas M. Diplopia after surgical repair of orbital floor fractures. Ophthal Plast Reconstr Surg 1996; 1:9-16.

Bracken MB, Shepard MJ, Collins WF et al. A randomised, controlled trial of methyl prednisolone or naloxone in the treatment of acute spinal cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Eng J Med 1990; 322:1405-11.

Crompton MR. Visual lesions in closed head injury. Brain 1970; 93:785-92.

Dutton JJ. Management of blowout fractures of the orbital floor. Editorial. Surv Ophthalmol 1990; 35:279-80.

Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness following blepharoplasty: two case reports, and a discussion of management. Ophthalmic Surg 1990; 21:85-9.

Goldberg RA, Steinsapir KD. Extracranial optic canal decompression: indications and technique. Ophthal Plast Reconstr Surg 1996; 12:163-70.

Gross CE, DeKock JR, Panje WR, et al. Evidence for orbital deformation that may contribute to monocular blindness following minor frontal head trauma. J Neurosurg 1998; 55:963-6.

Guy J, Sherwood M, Day AL. Surgical treatment of progressive visual loss in traumatic optic neuropathy. Report of two cases. J Neurosurg 1989; 70;799-801.

Harris GJ, Garcia GH, Logani SC, Murphy ML. Correlation of preoperative computed tomography and post operative ocular motility in orbital blowout fractures. Ophthal Plast Reconstr Surg 2000; 16:179-87.

Rose GE, Collin JRO. Dermofat grafts to the extraconal orbital space. Br J Ophthalmol 1992; 76:408-11.

Smith B, ReganWF Jr. Blowout fracture of the orbit: mechanism and correction of internal orbital fractures. Am J Ophthalmol 1957; 44:733-9.

Steinsapir KD, Goldberg RA. Traumatic optic neuropathy. Surv Ophthalmol 1994; 38:487-518.

Streitman MJ, Otto RA, Sakal CS. Anatomic considerations in complications of endoscopic and intranasal sinus surgery. Ann Otol Rhinol Laryngol 1994; 103:105-9.

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