Med. J. Cairo Univ., Vol. 82, No. 2, December: 253-255, 2014
www.medicaljournalofcairouniversity.net
Case Report:
Central Retinal Vein Occlusion Following Spontaneous Orbital
Emphysema
ABDULRAHMAN M. AL-AMRI, M.D.
The Department of Ophthalmology, College of Medicine, King Khalid University, KSA
Abstract
ocular pressure and rarely central retinal artery
occlusion [1] .
Purpose: To document the development of central retinal
vein occlusion secondary to orbital emphysema following
nose blowing.
Spontaneous orbital emphysema in the absence
of any significant trauma can occur as a result of
nose blowing, coughing, or sneezing [2-4] . In most
cases, orbital emphysema is an incidental benign
finding that resolves over with time. In the absence
of any acute compartment syndrome, careful observation is the treatment of choice unless an orbital
fracture exists involving an infected sinus, in which
case prophylactic orally administered antibiotics
are recommended [5-7] .
Methods: A 55-year-old male developed central retinal
vein occlusion secondary to orbital emphysema following
nose blowing in the absence of trauma.
Results: With conservative management his central retinal
vein occlusion resolved over nine weeks period.
Conclusion: The physician needs to be aware of possible
sequelae related to orbital emphysema following nose blowing.
A review of the medical literature revealed this to be, to the
best of our knowledge, the first reported case of this type.
Key Words: Central retinal vein occlusion – Orbital emphysema – Noseblowing.
To the best of our knowledge, central retinal
vein occlusion in a healthy male following nose
blowing in the absence of any history of trauma
has not previously been reported in literature.
Introduction
Case Report
RETINAL vascular occlusion may occur due to
orbital emphysema following vigorous nose blowing. With forceful nose blowing, a dehiscence or
perforation can occur between one of the orbital
walls and the adjacent sinuses allowing a communication between the orbit and the sinuses. Air then
accumulatesin the orbit, soft orbital tissue, such
as fat, then falls back on this communication,
blocking the exit of air and creating a one-way
valve. The trapped air can raise the intraorbital
pressuretherefore the venous circulation pressure
build up leading to retinal hemorrhages and macular
edema. If severe it can lead to acute compartment
syndrome and subsequent proptosis, elevated intra
A 55-year-old male presented to the researcher
at Abha Private Hospital, in April 2012, with a
one-day history of sudden onset of swelling of the
left periorbital area following forceful nose blowing
associated with blurred vision and mild ocular
pain.Nose blowing was advised by the ENT specialist to treat his otitis media. The patient denied
any history of sinusitis, trauma or any recent head
and neck surgical procedure. There was no previous
history of any allergies or medical problems.
On examination, his best corrected visual acuity
was 20/40 in the left eye, and the intraocular
pressure was 25mmHg. Left eye examination
showed mild periorbital swelling and non-tender
palpable crepitus. There was no ecchymosis, and
extra ocular motility was within normal limits.
There was no relative afferent pupillary defect.
Correspondence to: Dr. Abdulrahman M. Al-Amri,
The Department of Ophthalmology, College of Medicine,
King Khalid University, KSA
253
254
Central Retinal Vein Occlusion Following Spontaneous Orbital Emphysema
Slit lamp biomicroscopic examination showed
venous tortuosity, diffuse retinal hemorrhages and
focal macular edema which was confirmed on
fundus fluorescein angiography (Fig. 1).
Examination of the right eye was normal.The
patient was advised not to blow his nose forcefully
or perform activities that might elevate orbital
pressure. He was followed-up closely without
prophylactic antibiotics, and the emphysema resolved gradually over a 4-day period, while his
retinal hemorrhages resolved over 9 weeks period.
The patient refused focal laser photo coagulation
which was offered during his follow-up. Oneyear
follow-up examination showed best-corrected visual acuity of 20/40 and persistent focal macular
edema.
Fig. (1): Left fundus showing venous tortuosity and diffuse retinal hemorrhages. Left fundus fluorescein angiogram showing
focal macular edema.
Discussion
Retinal vascular occlusion due to orbital emphysema can occur following vigorous nose blowing. However, trauma has been reported to be the
most common cause of orbital emphysema. Orbital
emphysema after nose blowing is usually associated
with recent or past history of skull trauma and in
very rare instances it can present spontaneously
[1] .
Spontaneous orbital emphysema following nose
blowing has been reported, in addition to orbital
floor fracture and subsequent orbital cellulitis in
one case [3,4] . In another instance, bilateral subcutaneous orbital emphysema following nose blowing
in the absence of any previous history of trauma
in a 61-year-old male has been reported [3] .
Our patient had no history of previous trauma
and orbital emphysema that developed suddenly
after an incident of nose blowing.In the absence
of trauma, it has been proposed that increased intra
nasal pressure by nose blowing can cause a tear in
the thin lamina papyracea which may not be visible
in radiological studies,resulting in orbital emphysema [3] .
Orbital emphysema has been usually regarded
as a benign self-limited phenomenon. In most
instances, small amounts of trapped air in the
enclosed orbit has no significant consequences.
However, large pockets of orbital emphysema may
cause elevated intra ocular pressure, significant
proptosis, ocular motility deficit and in very rare
instances vascular compromise secondary to a
compartment syndrome [1] .
Because of the potential for severe visual loss,
the rapid diagnosis and management of orbital
emphysema is indicated. Fortunately, our patient
had clinical evidence of resolving orbital emphysema. Simple close observation of this patient
resulted in the disappearance of his clinical signs.
No further radiological study was indicated, since
there was no clinical evidence of motility disturbance, significantly elevated intraocular pressure
or compressive optic neuropathy. The role of
Abdulrahman M. Al-Amri
antibiotics is not clear, but most reports indicate
the use of antimicrobial therapy especially in the
event of concomitant sinusitis for fear of orbital
cellulitis [3,4] .
In summary, to the best of our knowledge,this
is the first reported case of central retinal vein
occlusion following a forceful nose blowing in the
absence of any history of trauma. The treating
physician needs to be aware of possible sequelae
related to orbital emphysema following nose blowing. Close observation is warranted to avoid serious
complications.
255
2- SHAH N.: Spontaneous subcutaneous orbital emphysema
following forceful nose blowing: Treatment options.
Indian. J. Ophthalmol., 55: 395, 2007.
3- MOHAN B. and SINGH K.P.: Bilateral subcutaneous
emphysema of the orbits following nose blowing. J.
Laryngol. Otol., 115: 319-20, 2001.
4- OLUWOLE M. and WHITE P.: Orbital floor fracture
following nose blowing. Ear Nose Throat J., 75: 169-70,
1996.
5- KHADER Q.A. and ABDUL-BAQI K.J.: Orbital emphysema after a protracted episode of sneezing in a patient
with no history of trauma or sinus surgery. Ear Nose
Throat J., 89: E12-3, 2010.
References
6- CHIU W.C., LIH M., HUANG T.Y., KU W.C. and WANG
W.: Spontaneous orbital subcutaneous emphysema after
sneezing. Am. J. Emerg. Med., 26: 3 8 1.e 1 -2, 2008.
1- LINBERG J.V.: Orbital Emphysema complicated by acute
central retinal artery occlusion: Case report and treatment.
Ann. Ophthalmol., 14: 747-9, 1982.
7- GONZALEZ F., CAL V. and ELHENDI W.: Orbital emphysema after sneezing. Ophthal. Plast. Reconstr. Surg.,
21: 309-311, 2005.