Back to Basics: Orbital Compartment Syndrome

Retrobulbar Hematoma and Orbital Compartment Syndrome 


Retrobulbar hematoma - bleeding into the post-septal space classically caused by blunt trauma to the eye, can lead to orbital compartment syndrome 


Orbital compartment syndrome: intraocular pressure (IOP) >40mmHg (Normal IOP: 10-21mmHg) in setting of retrobulbar hematoma 

  • --> Causes compression of ophthalmic artery and ocular nerve which can lead to ischemia and vision loss 

  • --> Signs and symptoms include proptosis, decreased visual acuity, afferent pupillary defect, ophthalmoplegia, severe eye pain 

  • --> Treatment is emergency lateral canthotomy and ophthalmology consult 


How to Perform a Lateral Canthotomy 

  1. Clean lateral canthus with antiseptic solution 

  1. Inject lidocaine with epinephrine in lateral canthus 

  1. Crush lateral canthus with hemostat for 1-2 minutes 

  1. Cut lateral canthus with iris scissors - incision should be approximately 1-2cm in length and depth 

  1. Retract lower lid to reveal lateral canthal tendon 

  1. Cut inferior crus of lateral canthal tendon 

  1. Repeat IOP measurement 

  1. If pressure remains elevated >40mmHg, should cut superior crus 


Complications - bleeding, infection, mechanical injury to surrounding structures 



Knoop, K. And Dennis, W. Ophthalmologic Procedures.” Roberts and Hedges’ Clinical Procedures in Emergency Medicine and Acute Care, 7th Ed. James R. Roberts, et al. Philadelphia, PA: Elsevier, 2019. 


Walker, R and Adhikari, S.. Eye Emergencies.” Tintinallis Emergency Medicine: A Comprehensive Study Guide, 8th Ed. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.