Optic Nerve Infarct Following Medial Orbital Wall Fracture Complicated by Orbital Emphysema
Mizna Akbar, Nikita Mokhashi, Christopher M. Maatouk, Hassan A. ShahPurpose:
We present a patient with an optic nerve infarct after a recent medial orbital wall fracture. The suspected mechanism was a transient orbital compartment syndrome or localized air bubble in the orbital apex, as the patient presented with pain in the affected eye, with sneezing as a potential trigger.
Observations:
A 66-year-old male presented to the outpatient ophthalmology clinic with persistent left eye pain and swelling. Four days prior, a fall led him to the emergency department (ED), where computed tomography (CT) showed a left medial orbital wall fracture. Initial visual acuity was 20/20 and 20/40. Intraocular pressure (IOP) was 9 and 22 mmHg in the right and left eyes respectively. There was mild limitation of left eye supraduction and infraduction. Repeat CT demonstrated orbital emphysema, and he was given a methylprednisolone dose pack and strict sinus precautions. Fifteen hours after the clinic visit, nearly 5 days after his fall, he presented to the ED with left eye pain and with no light perception (NLP) in the left eye, an IOP of 26, non-reactive pupil with a left afferent pupillary defect, and near complete ophthalmoplegia. He reported sneezing multiple times overnight. He received IV steroids and underwent emergent lateral canthotomy with superior and inferior cantholysis of the left eye, after which IOP was 19 in that eye. He remained NLP, and Magnetic Resonance (MR) imaging demonstrated an ischemic infarct within the optic nerve.
Conclusions and importance:
While rare, vision loss can occur as a complication of orbital emphysema (OE). Providers may consider recommending patients check their vision after any Valsalva inducing event. Possible interventions for OE, if vision-threatening, include emergent cantholysis and needle decompression.