Clinical Communications: Adult EMERGENCY DECOMPRESSION OF ORBITAL EMPHYSEMA WITH ELEVATED INTRAORBITAL PRESSURE Abdul Shameer, MD, Neelam Pushker, MD, Gautam Lokdarshi, MD, Shabeer Basheer, MD, and Mandeep S. Bajaj, MS Oculoplastic and Pediatric Ophthalmology Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India Reprint Address: Gautam Lokdarshi, MD, Oculoplastic and Pediatric Ophthalmology Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110 029, India , Abstract—Background: A case of orbital emphysema associated with elevated intraorbital pressure, presenting as a complication of a paranasal sinus ‘‘blow-out’’ fracture after trauma to the orbit and globe is presented. Case Report: A 45-year-old man developed left globe rupture with orbital emphysema after blunt trauma. A large air pocket in the superior orbit with medial wall fracture and globe tenting was identified on noncontrast computed to- mography. Direct needle drainage was performed using a 23-gauge needle attached to a saline-filled syringe with the plunger removed. Rapid release of air bubbles with prompt alleviation of pressure symptoms was observed. Why Should an Emergency Physician Be Aware of This?: Early diagnosis and management of orbital emphysema can salvage useful function of the globe. The knowledge of this clinical entity and its management can prevent delay and unnecessary re- ferral. Ó 2016 Elsevier Inc. All rights reserved. , Keywords—orbit; emphysema; aspiration; needle; air INTRODUCTION Orbital emphysema is a medical emergency and its im- mediate diagnosis and management is critical (1). Herein we have described needle drainage technique with the help of a video demonstration, which we believe to be the ideal method for evacuating orbital emphysema. CASE REPORT A 45-year-old man presented in Eye Casualty 6 h after a blow with a fist to the left eye. On examination, vision in the affected left eye was limited to the perception of light, and the best corrected visual acuity of the unaffected right eye was 20/20. There was painful restriction of extraocular movements of the left eye with inferior globe dystopia, conjunctival chemosis, corneal perforation, hyphema, and severe hypotony (Figure 1A and 1B). Crepitations were present in the upper lid. Retropulsion was not attemp- ted in view of globe perforation. Noncontrast computed tomography (NCCT) revealed a large air pocket in the left superior orbit and a medial wall blow-out fracture, along with tenting of the globe and stretching of the optic nerve (Figure 2). There was no entrapment of muscle or soft tissue at the fracture site. Paraocular ultrasonography revealed multiple air echoes in the superior orbit (Figure 3). With the patient lying supine, a 23-gauge (23G) needle along with a 10-mL syringe (with the plunger removed) was inserted in the upper lid tissue at the most bulging site (Video 1, available online), with the needle directed toward the orbital roof (away from the globe). An assistant filled the syringe from behind with normal Streaming video: A brief real-time video clip that accom- panies this article is available in streaming video at www.jour nals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1. RECEIVED: 3 May 2016; FINAL SUBMISSION RECEIVED: 5 August 2016; ACCEPTED: 14 October 2016 405 The Journal of Emergency Medicine, Vol. 53, No. 3, pp. 405–407, 2017 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2016.10.021