Diagnosis and management of orbital compartment syndrome caused by retrobulbar hematoma following orbital fractures.

While challenging, early diagnosis and appropriate management of retrobulbar hematoma (RBH) with orbital compartment syndrome (OCS) may improve patient prognosis. Our objective was to characterize OCS caused by RBH to establish clinically relevant management recommendations. A retrospective monocentric study was performed between 2018 and 2024 to evaluate the management and visual outcomes of patients treated in our department for RBH with OCS. In addition, to compare our results, a scoping literature review was performed to include all patients with the same characteristics (RBH with OCS). Our study involved a cohort of patients managed in our department for post-traumatic RBH with OCS. Visual acuity was assessed by the ability to count fingers at 1 m. In total, 3229 patients were managed in our department for a radiologically confirmed orbital fracture between 2018 and 2024. Of these, 81 patients (2.5 %) with a post-traumatic RBH were identified, including 14 (17 %) with OCS. Surgical decompression was most frequently realized for patients with an improvement in final visual acuity (recovery group; 72 %), compared with those without improvement or presence of blindness (sequelae group; 60 %). The median time between diagnosis and management was shorter in the recovery group compared with the sequelae group (6 h [20 minutes-12 h] versus 12 h [3-33h], respectively). These findings were supported by previously published data, with 81 reported RBH cases associated with OCS. To assess these data, an analysis of cases published in the literature between January 1950 and December 2023 was performed. Overall, 93 cases of post-traumatic and/or postoperative RBH were identified in 32 articles. Our study confirmed that OCS with visual acuity impairment caused by RBH is a maxillo-facial emergency, mainly occurring following orbital fractures. In cases of impaired visual acuity or relative afferent pupillary defect (RAPD), lateral canthotomy combined with cantholysis remains a simple procedure to reduce intraorbital pressure. Moreover, surgical decompression under general anesthesia should be performed emergently, ideally within 6 h following the trauma. However, visual recovery is possible even if surgery is performed beyond 6 h. Finally, visual acuity should be checked every 2 h for at least 24 h following orbital fracture surgery.