The man in the photo below was seen 6 hours after trauma. His vision is CF ou, he has a left RAPD and his IOP is 50mmHg. What should be your first line of therapy?

Correct Answer: Decompression of the orbit

This man has bilateral retrobulbar hematomas that are compressing the optic nerves. His vision is compromised, he has evidence of optic nerve damage and his pressure is elevated. In this situation, it is imperative to decompress the orbit in order to restore vision. An immediate lateral canthotomy with inferior cantholysis should be performed. If the hematoma occurs after surgery, the incision should be opened and the bleeder identified and stopped, and the hematoma evacuated. If the pressure is still elevated, the superior crus of the lateral canthal tendon can be lysed and beyond that, a bony decompression must be performed. In the case of a retrobulbar hematoma with pressure below 30mmHg and no visual compromise, observation is reasonable. If the pressure is above 30mmHg and there is no visual compromise or optic nerve damage, pressure lowering agents can be used.