Presenting Author:Dr.Ankita Mulchandani, Co Authors:Dr. Mehul Shah, Dr.Shreya Shah, Dr.Anand Tibdewal, Dr. Narayan Alane

1. TENSION PNEUMO-ORBIT:A
RARE TENSION
PRESENTING AUTHOR:
DR.ANKITA MULCHANDANI
CO AUTHORS:
DR. MEHUL SHAH
DR.SHREYA SHAH
DR.ANAND TIBDEWAL
DR. NARAYAN ALANE
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TOKEN NO: 0347
The authors have no financial interests to disclose

2. INTRODUCTION
• Orbital floor fractures are generally the result of blowout of
orbitand may be associated with orbital emphysema also called
as pneumoorbit
• It is a benign condition which is caused due to trauma in the
lamina papyracea or the orbital floor. Lyoid reported that 50% of
the orbital fractures have radiological evidence of air, especially
those involving the medial wall
• Emphysema is harmless unless there is a check valve which
prevents the air from leaving the orbit.
• If large amount of air enters the orbit, the intraorbital pressure
may increase, may constrain blood flow and cause the orbital
compartment syndrome
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3. • A 16-year-old boy sustained orbital fractures during road
traffic accident. He presented to us 12 days later with
painful proptosis in right eye
• A cursory ophthalmologic examination showed left
subcutaneous and subconjunctival emphysema
• The visual acuilty was no perception of light, and a
relative afferent pupillary defect in right eye
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4. • There was limitation in right eye movements in all
gazes,but able to close the eye and no paresthesia of the
cheek or teeth.
• A slit-lamp examination showed normal anterior
segment.The posterior segment showed signs suggestive
of optic atrophy.
• The intraocular pressure measured by indentation
tonometry was 20 mmHg.
• There was 4mm of proptosis in
the right eye compared with the
left eye, associated with crepitus
• The left eye was normal .
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5. • An orbital computed tomography scan showed a right
linear, non displaced fracture of the medial wall,orbital
floor and roof associated with peribulbar and
retrobulbar emphysema without muscle entrapment or
fat herniation.
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6. • Under local anesthesia right lower eyelid,20-gauge needle
attached to a 5-cm3 syringe filled with some normal saline was
introduced transcutaneously into the inferior orbit at the junction
of the middle and lateral thirds of the inferior orbital margin.
• The plunger was forced back spontaneously as the air pocket
was entered with aid of an assistant by squeezing the lesion.
• Finally, a total of 6 mL of air
was aspirated
•The patient was treated with
prophylactic broad -spectrum
oral antibiotics, lubricating eye
drops and systemic
corticosteroid
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7. Relief of proptosis, free movementin
all gazes but no improvement in vision
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8. Discussion
• Pneumo orbit is the abnormal presence of air within the fascial
layers of the orbit.
• About 63% of cases occur as a result of blunt orbital or facial trauma
involving nose and paranasal sinuses .Infrequent sources of
intraorbital air include postoperative complications, infection,
esophageal rupture, spontaneous pneumothorax ,etc .Predisposing
factors include sneezing and nose blowing.
• Orbital emphysema is often a benign and self-limited but if orbital soft
tissues lock the bony defect ,produce a one-way check valve,it may
elevate pressure high enogh to occlude retinal vasculature by causing
orbital compartment syndrome
• Diagnosis of orbital emphysema is made from the history with sudden
periorbital swelling and closing of the eyelids on the affected side, and
signs of crepitation, tenderness, pain and ecchymosis and confirmed
by orbital CT 8

9. • Conservative non-surgical approach includes treatment
with antibiotics, antiinflammatory drugs, and high-dose
corticostroids
• Surgical treatment of tension emphysema includes lateral
canthotomy or cantholysis, orbital decompression via
needle aspiration, transconjunctival or lateral
blepharoplasty approach and bone decompression
• Needle decompression is a simple, rapid technique,
described by Lindberg,and provides a treatment option for
patients with orbital emphysema associated with the
presence of proptosis, elevated IOP, and progressive loss of
vision due to vascular compromise or stretching of the
optic nerve.
• Potential complications require careful consideration, such
as retrobulbar hemorrhage, scleral perforation and optic
nerve damage.
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10. • Our case is an example of an 3 wall orbital fracture
complicated with orbital emphysema requiring an
urgent management
• The typical predisposing constellation of orbital wall
rupture,the presence of proptosis, elevated IOP and
loss of vision demanded acute management
• We preferred to perform decompression with a 20G
needle .
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11. Conclusion
• If tension emphysema occurs, the orbit must be
decompressed to relieve the compressive effect
of the air accumulation giving consideration to
vision and therapeutic complications
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12. References
1. Singh, M., Phua, V.M., and Sundar, G. Sight-threatening orbital
emphysema treated with needle decompression. Clin Experiment
Ophthalmol. 2007; 35: 386–387
2. Lee, S.L., Mills, D.M., Meyer, D.R., and Silver, S.M. Orbital
emphysema. Ophthalmology. 2006; 113:2113.e1–2113
3. Bastion, M.L. and Wong, Y.C. A case of sneezing-related orbital
emphysema treated by aspiration-decompression in the
office. Ophthal Plast Reconstr Surg. 2006; 26: 500–501
4. Dobler, A.A., Nathenson, A.L., Cameron, J.D., Carpel, E.T., Janda,
A.M., and Pederson, J.E. A case of orbital emphysema as an ocular
emergency. Retina. 1993; 13: 166–168
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