During ethmoidectomy under general anaesthesia, the orbit suddenly becomes tense with proptosis and a fixed dilated pupil. What is the immediate operative response?
This is orbital compartment syndrome threatening retinal and optic-nerve perfusion. Release orbital pressure at once, control the bleeding source and obtain ophthalmic support; CT must not delay decompression.
A. Reverse anaesthesia, wake the patient and measure visual acuity before intervening: A fixed pupil and tense proptotic orbit under anaesthesia are sufficient to treat; awakening creates a vision-threatening delay.
B. Perform urgent CT angiography before opening the lateral canthus: Imaging may define anatomy later but must not delay emergency decompression.
C. Stop the procedure and decompress the orbit immediately, including lateral canthotomy–cantholysis when indicated, without waiting for imaging: This is orbital compartment syndrome threatening retinal and optic-nerve perfusion. Release orbital pressure at once, control the bleeding source and obtain ophthalmic support; CT must not delay decompression.
D. Tamponade the ethmoid cavity firmly and reassess pressure after 30 minutes: Nasal packing alone does not reliably relieve an established orbital compartment syndrome and may worsen orbital pressure.
E. Complete the planned ethmoidectomy to identify the vessel: The elective procedure stops; decompression and haemostasis take priority over completing dissection.
If there were mild periorbital bruising, a soft orbit, reactive pupil and normal vision after surgery, urgent examination and monitored imaging—not automatic canthotomy—would be appropriate.
Independent Clinora educational material; not official JCIE content, an accredited programme, clinical advice, or a substitute for local policy and specialist judgement.
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