During the Spotlight on Ocular Trauma session on Sunday, Jurij R. Bilyk, MD, provided tips for managing 2 types of serious trauma that ophthalmologists may face: orbital compartment syndrome (OCS) and traumatic optic neuropathy (TON). “One is eminently treatable, and one has no effective therapy,” said Dr. Bilyk, before detailing the dos and the don’ts for these urgent conditions.
Managing OCS
Timely management. “This is critical,” he said, adding that delaying a treatment can result in severe visual loss.
IV mannitol can buy you time. While mannitol is not a definitive treatment, and a cantholysis is still necessary, the drug can decrease orbital and intraocular pressure. Dr. Bilyk cautioned that there are contraindications to mannitol, and he recommended consulting emergency room physicians prior to administration.
Don’t wait for imaging! OCS is a clinical, not a radiographic, diagnosis. You don’t need to wait for CT scans to proceed with a cantholysis.
An orbital blowout fracture does not always protect against OCS. Although this type of break can effectively decompress the orbit, that is not always the case.
IOP is a good measure of what is going on in the orbit. You can use IOP to gauge whether your intervention has worked. IOP should improve following a cantholysis. Dr. Bilyk noted that continued bleeding or the presence of pus may skew readings.
Managing TON
TON may resolve on its own. “Between one-third and two-thirds of TON patients will improve with observation alone. Make sure you document in the chart why you’re doing nothing.”
Don’t give megadoses of steroids. There is solid evidence showing that giving steroids to patients with traumatic brain injury increases morbidity and mortality. “It’s contraindicated; we shouldn’t use it,” according to Dr. Bilyk.
Don’t make assumptions about APD in comatose patients. Remember that the absence of an afferent pupillary defect (APD) does not rule out bilateral symmetric TON. Moreover, an APD on one side does not mean that the other is normal—an asymmetric bilateral TON can present with a unilateral APD. Wait until the patient is awake so that you can perform a full exam.
No evidence for surgical intervention. Surgery carries a large risk, as physicians are working in a tight area in the skull base with delicate structures nearby. A prior cadaver study suggested that the act of doing a canal decompression may cause more harm than good to the optic nerve.—Keng Jin Lee
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