Venous Occlusion in a Case of Orbital Cellulitis

Dear Editor, Orbital compartment syndrome (OCS) is one of the few emergencies in ophthalmology which if not handled urgently , can lead to catastrophic results. Multiple etiologies such as retro-bulbar hemorrhage, trauma, orbital mass and sometimes orbital cellulitis/abscess have been implicated. We report an uncommon association of subhyaloid hemorrhage secondary to retinal venous stasis in a commonly seen case of orbital abscess with active dacryocystitis. A young man presented with gradually progressive swelling over the right eye after 2 days of throbbing pain and high grade fever. On examination, there was marked lid edema, ecchymosis with subdued extraocular muscle movements in all gazes and 8-mm abaxial proptosis of the right eye directed infra-temporally. A best-corrected visual acuity of 1 / 60 in the right eye and 6 / 6 in the left eye was recorded. Pupillary reaction of the right eye showed relative afferent pupillary defect. Conjunctival congestion with minimal chemosis in the right eye was also noted. Fundos-copy revealed disc edema with marked venous dilatation and tortuosity, a massive subhyaloid hemorrhage measuring four disc diameters, overlying the center of macula, along with multiple superficial hemorrhages all around the disc (Fig. 1A). Blood workup was suggestive of neutrophil-ia. A contrast enhanced computed tomography scan was obtained that demonstrated proptosis of the right globe with subcutaneous edema overlying the right orbit and right infratemporal fossa and infective foci localized to the lacrimal sac area (Fig. 1B). The patient was empirically initiated on intravenous ceftriaxone and metronidazole along with supportive measures. Within 24 hours, there was a marked drop in fever; however the size of swelling increased and a pus point appeared on the lower lid (Fig. 1C). Visual acuity (VA) dropped to hand movements close to the face in the right eye and intraocular pressure appeared to be raised digitally. VA dramatically improved to counting fingers at 2 m after pus drainage. As the orbital pressure started normalizing, Nd: YAG (neodymium: yt-trium aluminum garnet) hyaloidotomy of the subhyaloid hemorrhage was performed at the most dependent position. The patient was discharged when extraocular movements recovered in all gazes and pupillary reactions were normal, and was followed up regularly for resorption of the bleed. At 6 months, his VA recovered to 6 / 6 and he was discharged from follow-up. OCS is characterized as a rise of intraorbital pressure that results in impaired vascular perfusion of the optic nerve and globe. Loss of …