Extensive orbital and parapharyngeal emphysema requiring urgent canthotomy and cantholysis after pars plana vitrectomy

Authors: Georges Nassrallah, Harrish Nithianandan, Abdullah Al-Kaabi, Michael Politis, Thalmon Campagnoli, Zainab Khan, Michael A. Kapusta.

Author Disclosure Block: G. Nassrallah: None. H. Nithianandan: None. A. Al-Kaabi: None. M. Politis: None. T. Campagnoli: None. Z. Khan: None. M.A. Kapusta: None.

Abstract Body:

Purpose: We report the presentation and emergent management of a rare case of orbital and parapharyngeal emphysema causing orbital compartment syndrome and signs of peripheral neuropathy days after uneventful pars plana vitrectomy.
Study Design: Case report and review of the literature.
Methods: The patient’s medical chart was reviewed, and a comprehensive literature review was conducted.
Results: A 20-year-old female with a history of treated retinopathy of prematurity underwent three-port 23-gauge pars plana vitrectomy in the right eye for subtotal retinal detachment under general anesthesia. All sclerotomies were secured with 7-0 Vicryl sutures prior to instillation of 15% C3F8 gas. On the third postoperative day, the patient presented with a 3 mm proptosis, near total ophthalmoplegia, difficulty breathing, jaw protrusion, head deviation, tongue protrusion and facial twitching. Subcutaneous emphysema was noted over the face and neck and intraocular pressure (IOP) was 14 mmHg. Computed tomography showed extensive subcutaneous gas in the right orbit and bilateral parapharyngeal spaces, and a tethered right optic nerve with globe tenting. Given the findings within the right orbit on computed tomography and the patient’s neurological symptoms, a decision was made to perform urgent lateral canthotomy and cantholysis (CC). Three hours after CC, her neurological signs had resolved except for intermittent tongue deviation, which resolved by the next day. At postoperative week 7, the patient’s vision was 20/70 and her IOP was 13. Her extraocular movements were full and her retina was flat.
Conclusions: To our knowledge, this is the only report of a modern small-gauge vitrectomy procedure being complicated by orbital compartment syndrome and extensive emphysema causing peripheral neuropathy, and successfully treated with urgent canthotomy and cantholysis.