Traumatic Orbital Compartment Syndrome in Children-Systematic Review and Descriptive Summary

What are the epidemiology, mechanisms, management strategies, and visual outcomes of traumatic orbital compartment syndrome (OCS) in children?

Traumatic OCS is a rare but vision-threatening emergency requiring rapid recognition and intervention. In children, diagnosis and management are challenging due to age-specific anatomy, limited cooperation, and heterogeneous trauma mechanisms. Current management strategies are largely extrapolated from adult data, and no pediatric-focused systematic synthesis is available.

A systematic review was conducted in accordance with PRISMA guidelines. Embase, PubMed, and Web of Science were searched from inception to 10 December 2023, with an update on 9 October 2024 and 8 April 2025 using terms related to orbital compartment syndrome, orbital hematoma, trauma, and a validated pediatric search filter. Eligible studies included case reports and case series describing traumatic OCS in patients younger than 18 years. Three reviewers independently screened studies, extracted data, and assessed risk of bias using the Joanna Briggs Institute critical appraisal checklists for case reports and case series. Due to substantial heterogeneity, results were synthesized descriptively. The review protocol was registered prospectively in PROSPERO (CRD420251028845).

Of 1317 screened records, 90 studies were included, comprising 126 pediatric patients. Mean age was 10 years, with a male predominance (3.8:1). Falls and direct head trauma were the most common injury mechanisms. Subperiosteal hematoma was the predominant underlying pathology. Eleven patients had documented coagulopathies, frequently associated with extensive extracranial hematomas. Clinical presentation commonly included proptosis and visual symptoms, with onset either immediately after trauma or delayed by 4-7 days. Management strategies included observation (18/126), medical therapy (24/126), and surgical intervention (103/126; 70 as primary treatment). At a mean follow-up of 109 days, visual impairment was reported in 21 patients. Earlier surgical intervention was consistently associated with more favorable visual outcomes, although certainty of evidence was very low.

Evidence limited to case reports and small case series suggests that pediatric OCS differs from adult disease with regard to epidemiology and underlying pathophysiology. Despite very low certainty of evidence, consistent patterns support a time-critical, clinically driven management approach. A pragmatic diagnostic and treatment algorithm is proposed to support early recognition and timely intervention in children with suspected OCS.