A patient presents in a coma after head and face injury. You note proptosis and the CT shows retroorbital hematoma. You wonder whether you should decompress this. Normally we based decompression on visual acuity but that is not available in the comatose patient. What can we do?


Afferent pupillary defect (swinging flashlight test) may be an important finding in these patients. A recent review of 8 cases showed that it was present in 7 of the 8, and was not able to be tested in the 8th.(Sun MT EMA 2014)


Other objective findings would include firmness to palpation, which is helpful because when you decompress the eye you want to be able to confirm your procedure was effective. If the tense eye becomes soft, that is helpful. Measure intraocular pressure for an objective measure. Do not press on the eye if open globe is on the differential.


Take Home Points:

-Look for afferent pupillary defect in patients suspected of having orbital compartment syndrome

-Palpate the eye before and after decompression