Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXIV: Wounds and Injuries of the Eye
United States Department of Defense
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Orbit. A careful examination of the globe is mandatory in all cases of injury to the orbit. The globe is significantly injured in 25% of orbital fractures. Retrobulbar hemorrhage must be detected and treated if it is producing marked elevation of intraocular pressure and/or decreased visual acuity. If so, a lateral canthotomy and cantholysis of the inferior crus of the lateral canthal tendon should be performed. If these maneuvers do not produce an improvement in intraocular pressure (i.e., decreasing it) and vision, the hemorrhage must be released by an incision through the conjunctiva and Tenon's capsule between the lateral rectus and the inferior rectus muscle into the muscle cone. The incision should be made with sharp scissors, and blunt tip scissors should be used to gently spread the orbital fat within the muscle cone to permit the escape of blood. Pressure on the globe and optic nerve during any surgery upon the orbit and its contents must be avoided. Blindness can result from prolonged retraction pressure on the globe and nerve. Intraorbital extraocular foreign bodies are best left undisturbed unless they are large (greater than 1 cm in largest diameter) or are producing globe or optic nerve dysfunction. Radiographic evaluation of orbital fractures should include a stereo Waters' view and computerized tomography with coronal and sagittal reformatting. The latter is especially important in the evaluation of fractures of the optic canal. Blowout fractures of the orbital floor in general do not require immediate repair. Forced duction testing should always be performed before resorting to surgical repair. If surgery is performed, ductions of the globe should be tested intraoperatively to help prevent incarceration. of tissues incident to surgical manipulation.
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