Decompression Surgery of Orbital Compartment Syndrome Caused by Retrobulbar Hemorrhage – Analysis of Surgery Procedures and Visual Function

Objective: Various orbital conditions (trauma, autoimmune thyroid disease, tumors, infections, congenital malformations) may lead to retrobulbar hemorrhage (RBH) with a consecutive increase in orbital cavity pressure resulting in orbital compartment syndrome (OCS). OCS is associated with acute loss of visual function and a high risk of permanent damage to the optic nerve (compressive optic neuropathy). Orbital decompression surgery (ODS) is a time-critical procedure that reduces pressure on the optic nerve, thereby improving visual function. The surgical management protocol for orbital decompression is not standardized and varies. Surgical techniques differ in orbital fat decompression, lateral canthotomy, and decompression of the medial orbital wall and floor. This retrospective study aimed to evaluate surgery procedures and the outcome of visual function after orbital decompression surgery. Methods: In a retrospective study, we evaluated 28 patients (17 male, 11 female) with orbital compartment syndrome from May 2016 to October 2024. All patients underwent orbital decompression surgery as first-line treatment. Visual acuity (VA), diplopia, and ocular motility were analyzed pre- and postoperatively. Recovery was defined as postoperative improvement of vision, diplopia, and ocular motility. Linear and logistic regression analyses were used to assess the associations between clinically relevant risk factors and primary outcomes. Results: Orbital decompression surgery was performed with a median of 8.40 hours (Q1: 4.80, Q3: 24.00) upon occurrence of symptoms. The average preoperative measured vision was 0.23 (SD, 0.34). 46% of patients were preoperatively categorized as „blind“ according to the WHO visual impairment categories. 96% showed preoperative ocular motility impairment. Diplopia was preoperatively present in 46%. After orbital decompression surgery, postoperative visual acuity improved in 36% of the patients. Ocular motility improved by 67% and Diplopia by 62% after ODS. The primary surgery technique was 2-wall decompression in 68% (19/28) of cases, followed by 1-wall decompression (21%; 6/28) and 3-wall decompression (11%; 3/28). Lateral decompression (82%; 23/28) and medial wall decompression (93%; 26/28) were the primary procedures performed. Orbital floor wall decompression was performed in only 14% (4/28) of cases. Regression analysis revealed a statistically significant effect of preoperative measured vision on postoperative vision, while accounting for age, sex, and time to surgery. Conclusion: Orbital decompression surgery is the time-sensitive first-line treatment of acute visual function loss in OCS. Our data showed a postoperative improvement in visual acuity in 36% of patients, along with considerable improvement rates in diplopia and ocular motility. The primary surgery technique was a 2-wall-decompression approach with lateral wall decompression and medial wall decompression. Center-specific timeline optimisation of OCS patients is essential.