Acute Unilateral Periocular Emphysema After Whipple Procedure

A 76-year-old female with newly diagnosed pancreatic cancer underwent a 10-hour robotic Whipple procedure in a left lateral recumbent position. Immediately prior to extubation, the surgical team noticed significant right-sided subcutaneous emphysema of the chest, neck, and face. Ophthalmology was consulted, and a sedated exam demonstrated pupils without afferent pupillary defect, normal intraocular pressure OU, and crepitus of the right eyelids (Fig. 1A). Right lagophthalmos and prominent, diffuse subconjunctival emphysema were noted (Fig. 1B). Dilated fundus exam was normal OU. Given the patient’s soft orbit, lack of proptosis, and normal pupillary exam, the decision was made to pursue close clinical observation and defer orbital imaging at this time. Topical lubrication and night-time eyelid taping were initiated to minimize exposure keratopathy. After extubation, the patient denied any ocular complaints. Visual acuity, pupillary exam, motility, and color vision were normal. Her subconjunctival and palpebral emphysema improved (Fig. 2A,B). By postoperative day 5, the patient had trace residual subconjunctival and lid emphysema.FIG 1.: FIG 2.: Subcutaneous emphysema is a common complication of laparoscopic and robotic abdominal surgery. This is primarily attributed to the escape of carbon dioxide gas into the subcutaneous space during insufflation at the beginning of surgery. In contrast, subconjunctival emphysema is a rare complication of laparoscopy. This may be managed conservatively—as with this patient—but a low threshold for imaging and intervention should be maintained if concomitant signs of optic neuropathy, orbital compartment syndrome, or pneumothorax are observed.