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BMJ Open Ophthalmology logoLink to BMJ Open Ophthalmology
. 2026 Feb 18;11(1):e002460. doi: 10.1136/bmjophth-2025-002460

Reduced haemorrhage during external medial orbital wall decompression with nasal packing containing vasoconstrictive agent

Anna Helena Christina Wiktorin 1,2, Pär Stjärne 3,4, Elin Bohman 1,2,✉
PMCID: PMC12918663  PMID: 41708136

Abstract

Objective

In retrocaruncular medial decompression, the incision is small relative to the depth of the surgical space, and haemorrhage may obscure vision. Measures that minimise bleeding are most important to improve visualisation and facilitate the procedure. Despite this, there is no consensus regarding the effect of nasal packing with a vasoconstrictive agent. The aim of this study was to see if haemorrhage during external medial decompression could be reduced by nasal packing.

Methods and analysis

A randomised, non-blinded, prospective study in which patients listed for orbital medial wall decompression at St Erik Eye Hospital, Sweden, were recruited. Patients were randomised to receive either nasal packing with a 4%+0.02% Cocaine Hydrochloride-Adrenaline solution or the control group. Intraoperative bleeding was quantified by weighing the suction device before and after the procedure.

Results

A total of 46 medial orbital wall decompressions in 37 patients were included in the final analysis. The treatment group, which received nasal packing, demonstrated significantly reduced intraoperative bleeding compared with the control group (median 9.40 g vs 30.10 g, p<0.001). No surgical complications or postoperative infections were reported.

Conclusions

This study demonstrated a highly significant reduction in perioperative bleeding during retrocaruncular medial decompression when nasal packing with a vasoconstrictive agent was used (p<0.001). The main limitation of this study is the potential variability between surgeons. However, a post hoc test (p=0.75) and interaction analysis (p=0.63) did not reveal any differences between surgeons. In summary, nasal packing with a potent vasoconstrictor offers a simple, effective means to reduce intraoperative bleeding during external medial wall decompression and can thereby be an easy way to facilitate this surgical procedure and reduce the risk of complications.

Keywords: Orbit, Treatment Surgery, Treatment Expectations

WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Although minimising haemorrhage is critical for optimal visualisation during retrocaruncular medial orbital decompression, the effect of nasal packing with vasoconstrictive agents remains unclear, warranting further investigation into its clinical efficacy.

WHAT THIS STUDY ADDS

  • This study provides evidence that nasal packing with a vasoconstrictive agent significantly reduces intraoperative haemorrhage during retrocaruncular medial orbital decompression, supporting its use as a simple and effective method to optimise surgical conditions.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • The findings support the integration of nasal packing with a vasoconstrictive agent into standard surgical protocols for medial orbital decompression, offering a straightforward method to reduce intraoperative haemorrhage and improve operative conditions.

Introduction

Thyroid eye disease (TED) is a complex immune-mediated inflammation affecting the orbit. Approximately 40% of patients with Graves’ disease exhibit symptoms of TED.1 However, the clinical presentation may vary from unilateral dry eye to bilateral vision-threatening complications. Approximately 20% of patients suffer from sequelae requiring surgical rehabilitation in the late stage of the disease.2 Orbital decompression can be performed during the active stage of TED, if vision-threatening optical neuropathy does not respond to medical treatment, or during the late, inactive stages to reduce proptosis.3,6 The procedure involves the removal of one or several bony walls, fat resection or a combination, effectively reducing intraorbital pressure and proptosis.

In orbital surgery, which is often conducted in a confined area, a bloodless field is paramount since even minor bleeding can obscure the surgical field. Additionally, in retrocaruncular medial decompression, the surgical opening (approximately 10–15 mm) is small relative to the depth (approximately 45 mm) of the surgical space, and haemorrhage, typically from the ethmoidal cells, may obscure vision and make identification of the ethmoidal arteries challenging (figure 1). The vascular supply of the periocular region, orbit and nose is complex and stems from the internal as well as the external carotid arteries (figure 2). Furthermore, there is a dense network of connections and anastomoses between the branches originating from these two carotid arteries. The mucosa of the ethmoidal cells is supplied by the anterior and posterior ethmoidal arteries, which stem from the ophthalmic artery. In addition, the ethmoidal arteries supply the lateral wall of the nose and the nasal septum. The anterior and posterior ethmoidal arteries serve as important landmarks as they are located below the cribriform plate, marking the border to the brain. Perioperative damage to this bone can result in complications such as cerebrospinal fluid leak and intracranial air.5 7 8 Numerous methods to attain intraoperative haemostasis have been outlined, and optimal haemostasis is typically achieved through a combination of interventions rather than relying on a single approach.9

Figure 1. Representative example from one of the patients with CT scan images. The area highlighted in red indicates the planned surgical site for external medial orbital wall decompression. (A) Axial view. (B) Coronal view.

Figure 1

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Figure 2. Schematic illustration by M Ceder showing the arterial vascular supply to the medial part of the orbit, ethmoidal sinus and nose.

Figure 2

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As medial wall decompression and access to the medial orbit have become more common, it is increasingly important for orbital surgeons to understand the anaesthetic requirements for adjacent anatomical areas, such as the nose.9 Despite this, there is no consensus regarding the effect of nasal packing with a vasoconstrictive agent when performing external medial wall decompression. In some textbooks on orbital surgery, when entering the medial orbit, the use of a nasal tamponade with vasoconstrictive agents preoperatively is advocated to minimise bleeding.10 However, this is often not mentioned when describing the procedure of external medial wall decompression performed by oculoplastic surgeons.511,13 Further on, there have been no formal surveys regarding the use of nasal packing for orbital decompression. Anecdotally, the authors have surveyed multiple oculoplastic surgeons in the USA and Europe who have indicated that nasal packing is not a standard practice.

In contrast, ear-nose-throat (ENT) surgeons performing endoscopic medial wall decompression (where the same surgical space is entered) routinely place tamponades with a strong vasoconstrictive agent before the start of surgery to optimise the operative field and minimise bleeding from the nasal mucosa and ethmoidal cells.214,16

To what extent does a nasal tamponade with a potent vasoconstrictive agent affect intraoperative bleeding during orbital medial wall decompression via an external approach? Is this effect clinically significant? The aim of this study was to measure the reduction in bleeding to assess if preoperative packing of the nasal cavity with a tamponade containing a strong vasoconstrictive agent is a clinically relevant procedure. Measures that minimise bleeding in the surgical field are of utmost value to improve visualisation, facilitate the identification of important anatomical structures and reduce the risk of complications.

Methods

Patients

In a randomised, non-blinded, prospective study, patients scheduled for orbital medial wall decompression alone or as part of a two-wall or three-wall decompression at the Oculoplastic and Orbital Services at St Erik Eye Hospital, Solna, Sweden, were consecutively recruited during the period from 1 March 2022 to 11 June 2024. Patients and the public were not involved in the design, conduct or reporting of this research.

A power calculation was performed to determine the study population size. Measurements from five external medial orbital wall decompression procedures showed an average bleeding amount of 30.46 g with an SD of 9.995 g. We assumed a 25% reduction in bleeding to be clinically significant. To detect such a difference, 22 patients needed to be included in each group (significance level of 0.05, power 80%). We decided to include 25 patients in each group to allow for potential exclusions. Exclusion criteria included inability to provide informed consent, systolic blood pressure over 110 mm Hg for more than 5 min during the surgical procedure, anticoagulant therapy not adjusted according to local guidelines, complications with cerebrospinal fluid leakage and age below 18 years.

Surgical procedure

External medial wall decompression was performed by three experienced oculoplastic surgeons (coauthors AHCW, EB and Alexander Berg Rendahl, MD, PhD), following clinical practice and a standardised surgical approach. The external transcaruncular approach for medial decompression, as described by Shorr et al, was employed.12 An incision was made at the caruncle, followed by dissection along a natural plane between the orbital septum and Horner’s muscle towards the posterior lacrimal crest. The periorbita was incised along the posterior lacrimal crest, and dissection was then continued using a periosteal elevator along the subperiorbital plane. The periorbita was elevated both inferiorly and superiorly to create a wide anterior aperture. This broad exposure facilitated access to the medial orbital wall and apex, allowing for removal of the medial wall along with the underlying ethmoidal cells. Excision of the periorbita enabled orbital tissues to expand into the newly created space, thereby reducing proptosis and pressure on the optic nerve. No fat removal was performed in this area.

The patients were randomised to either receive a nasal tamponade (the treatment group) containing 4%+0.02% Cocaine Hydrochloride-Adrenaline solution (APL, Stockholm, Sweden) or the control group, which underwent the same procedure without nasal packing. The nasal packing on the affected side consisted of two cocaine-soaked neurosurgical Cottonoid patties, one inserted back into meatus superior and one in meatus media. The packing was conducted after induction of general anaesthesia but before draping the patient. This allowed at least 15 min of effect before the start of surgery.

In order to standardise the procedure, all patients rested in a 30-degree reversed Trendelenburg position. The blood pressure and heart rate were kept as stable as possible, with a systolic blood pressure between 90 and 110 mm Hg. Local infiltration anaesthesia was achieved with a standardised dose of 1 mL Marcaine-Adrenaline 2.5 mg/mL+5 µg/mL (Marcaine-Adrenaline; Aspen Pharma, Dublin, Ireland). After injection, the solution was allowed to diffuse into the tissue for 2 min before surgery was started, to allow the local perfusion to stabilise and to achieve the full vasoconstriction effect of the adrenaline.17 Bipolar diathermy at 25 W (KLS Martin ME102; KLS Martin, Tuttlingen, Germany) was used with caution. The amount of perioperative haemorrhage was measured by weighing the suction device with a scale (Scout STX Series Balances; OHAUS, Parsippany, New Jersey, USA) before and after the surgical procedure. If the patient underwent a two-wall or three-wall procedure, the suction device was changed for the medial wall intervention, which was done as the last step. The haemorrhage was measured in grams with two decimals precision. To avoid interference with the measurements, no irrigation solutions were used during surgery, and no additional surgical gauze or similar methods for blood removal were applied.

At the end of surgery, patients received an orbital drainage and no-pressure dressing and were admitted one night at the hospital to monitor for retrobulbar haemorrhage or other complications. The day after surgery, the dressing and drainage were removed. All patients were prescribed postoperative application of topical antibiotic ointment in the operated eye until the clinical follow-up after approximately 1 week.

Calculations and statistical analysis

Generalised linear mixed‑effects models were used to examine the association between the perioperative bleeding and the use of nasal packing. Because perioperative bleeding showed a positively skewed distribution, we used a gamma family with a log link. Repeated measurements were accounted for by including a random intercept. We assessed whether the surgeon modified the effect of nasal packing on bleeding by evaluating the interaction between the surgeon and nasal packing. This included a joint test of the two‑way interaction terms and joint tests of the effect of nasal packing for each surgeon. The analyses were conducted in STATA V.16.1 (StataCorp. 2019. College Station, Texas, USA). The violin plot was created in R V.4.4.1.18

Results

In total, 50 medial orbital wall decompressions in 39 patients were recruited for the study. According to the exclusion criteria, one decompression was excluded due to high blood pressure above 110 mm Hg for more than 5 min during the procedure. Furthermore, three more decompressions had to be excluded due to deliverance problems of Marcaine-Adrenaline 2.5 mg/mL+5 µg/mL; these patients thereby received Xylocain Dental Adrenalin 20 mg/mL+12.5 µg/mL (Dentsply DeTrey, Konstanz, Germany) instead. In total, 46 decompressions in 37 patients were included in the study; 23 in the treatment group and 23 in the control group (table 1). The median age was 53 years (range 22–82 years); 13 (28%) were male and 33 (72%) were female. All the patients had TED, and the indication for decompression was vision-threatening optical neuropathy in 15 (33%) cases and proptosis reduction in 31 (67%) cases. 13 (28%) of the patients were taking antihypertensive medication and five (11%) were on anticoagulant medication, which was adjusted according to local guidelines. One patient, who underwent bilateral intervention and was randomised to the nasal packing group on both occasions, had activated protein C resistance and received perioperative anticoagulant treatment with low molecular weight heparin (Fragmin; Pfizer, Stockholm, Sweden).

Table 1. Baseline characteristics and crude comparisons between nasal packing and control group.

Total
n=46		 Nasal packing
n=23		 Control
n=23		 Test P value
Age 52.91 (SD 14.22) 54.57 (SD 13.43) 51.25 (SD 15.08) Independent t-test 0.43
Gender Χ2 0.33
 Male 13 (28%) 5 (22%) 8 (35%)
 Female 33 (72%) 18 (78%) 15 (65%)
Perioperative bleeding (g) 24.70 (SD 20.25) 14.58 (SD 13.80) 34.83 (SD 20.83) Independent t-test <0.001
Perioperative bleeding (g) 18.70 (IQR 7.41–33.75) 9.40 (IQR 5.43–17.40) 30.10 (IQR 18.70–45.90) Wilcoxon rank-sum <0.001
Acute decompression 15 (33%) 6 (26%) 9 (39%) Χ2 0.35
Bilateral decompression 37 (80%) 19 (83%) 18 (78%) Χ2 0.71
Bleeding disease 2 (4%) 2 (9%) 0 (0%) Χ2 0.15
Anticoagulant medication 5 (11%) 4 (17%) 1 (4%) Χ2 0.16
Antihypertensive medication 13 (28%) 8 (35%) 5 (22%) Χ2 0.33
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Data are presented as mean (SD) or median (IQR) for continuous measures, and n (%) for categorical measures.

Surgical outcome

There was a significantly reduced bleeding (p<0.001) in the treatment group compared with the control group (figure 3). The median perioperative bleeding in the treatment group was 9.40 g (IQR 5.43–17.40) compared with 30.10 g (IQR 18.70–45.90) in the control group. There were no surgical complications or postoperative infections. Further on, there was no major bleeding in either group. However, four patients, of which two underwent bilateral intervention, hence four in the treatment group and two in the control group, were clinically generally prone to bleeding during the procedure. One of these patients, randomised to the control group, had treatment for high blood pressure, but otherwise no risk factors, and received 1 g of tranexamic acid (Cyklokapron; Pfizer Manufacturing Belgium, Belgium) at the end of surgery as an extra precaution. This did not interfere with the measurements of perioperative bleeding. The other three patients were all healthy without additional risk factors. Of these three patients, one underwent bilateral intervention and was randomised to both the treatment group and the control group. During surgery without nasal packing, Surgicel (Ethicon, Neuchâtel, Switzerland) had to be placed along the posterior part of the ethmoid sinus for haemostatic purposes. During surgery with nasal packing, no intervention was needed. One patient in the treatment group had hard bone and large blood vessels and was generally prone to bleeding, but no extra precautions were indicated. The last of these four patients underwent bilateral surgery and was randomised to the treatment group both times. This was the only one of these four individuals who underwent acute surgery during active TED/inflammation, and on both occasions, this individual was clinically prone to bleeding, but no extra precautions were indicated.

Figure 3. Violin plots showing the amount of perioperative bleeding in grams without (red) and with (blue) nasal packing. There was significantly reduced bleeding (p<0.001) in the nasal packing group compared with the control group.

Figure 3

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A subgroup analysis was conducted to determine whether perioperative bleeding was influenced by the surgical indication—acute decompression for patients with vision-threatening optical neuropathy versus decompression for proptosis reduction. Of the total 46 decompressions, 15 (33%) were performed as acute procedures, with six of these (40%) randomised for nasal packing. The remaining 31 cases (67%) were performed for proptosis reduction, of which 17 (55%) received nasal packing.

The median perioperative bleeding in the acute decompression group was 18.70 g (IQR 10.40–46.75), compared with 18.70 g (IQR 6.54–33.70) in the proptosis reduction group. The subgroup analysis revealed no statistically significant difference in perioperative bleeding between the two indications (p=0.48). Additionally, interaction analysis and post hoc tests were conducted to determine whether differences existed between surgeons or whether surgeon type modified the effect of nasal packing on bleeding. No statistically significant crude differences were observed between surgeons (p=0.75) or for interaction (p=0.63).

Discussion

This study demonstrated a highly significant reduction in perioperative haemorrhage—by approximately two-thirds (p<0.001)—during external medial orbital wall decompression when a nasal tamponade containing a 4% Cocaine Hydrochloride-Adrenaline solution was used, compared with the control group without nasal packing. The 20.7 g difference in perioperative bleeding found in this study corresponds to a bleeding volume of 21.9 mL, assuming a blood density of 1.06 g/cm³ at 37°C.19 This finding is of high clinical relevance, as even a small reduction in bleeding facilitates the surgical procedure. Our results align well with endoscopic surgery practices, where nasal packing is mandatory to reduce swelling for better visualisation during the procedure and to minimise perioperative haemorrhage.

The literature on orbital decompression encompasses a wide range of techniques, with different surgical specialists performing the procedure, such as oculoplastic surgeons, ENT surgeons and neurosurgeons. Several reviews have been conducted to evaluate the different surgical approaches. However, comparing the effectiveness of different methods is challenging due to inconsistencies in inclusion criteria, reporting of complications and defining success criteria.24 11 20,26 If an endoscopic approach is performed, everyone, regardless of specialty, would use nasal packing. So why not use nasal packing when entering the same surgical space from the other side? de Lange et al could, in their study (The effect of nasal application of cocaine/adrenaline on blood loss in Le Fort I osteotomies) from 2008, present an average reduction in blood loss of more than 50% if nasal packing with cocaine-adrenaline was used.27 This is similar to the results of our present study, which demonstrated a highly significant reduction in haemorrhage when using nasal packing with a strong vasoconstrictive agent, compared with the control group.

The mucosa of the ethmoidal cells receives blood from the anterior and posterior ethmoidal arteries, which also supply the lateral nasal wall and nasal septum. During external medial orbital wall decompression, the nasal mucosa lies directly behind the surgical field, making haemostatic interventions targeting the nasal mucosa likely to affect blood flow, as shown in this study. The authors hypothesise that the deeper vascular effect of nasal packing with a vasoconstrictive agent is likely attributable to retrograde absorption of the anaesthetic solution. Although several studies have investigated the local vasoconstrictive effects of cocaine and adrenaline, as well as the systemic uptake of cocaine,28,37 we were unable to identify any studies that specifically monitor deeper anatomical structures or elucidate the precise mechanisms by which these are affected by nasal packing with local anaesthetics. This represents a compelling area for future research.

Various agents and techniques are available for local anaesthesia, vasoconstriction and decongestion of the nose.37,39 Historically, cocaine, which is the only substance to have both vasoconstrictive properties as well as an anaesthetic effect, has been widely used.37,39 However, cocaine is a controlled substance with specific requirements for storage and dispensing, and concerns have been raised regarding its potential systemic side effects even when applied topically.29 37 Adding adrenaline to nasal cocaine preparations enhances vasoconstriction,31 reduces blood loss and lowers systemic absorption.30 In this study, a 4% cocaine-adrenaline solution was used for nasal preparation without adverse effects. However, given the rarity of cocaine-related complications, a larger study is needed to fully evaluate the risk. Alternatives like lidocaine combined with oxymetazoline have been suggested.29 39 Future studies could explore whether these alternatives provide similar bleeding reduction during external orbital medial wall decompression.

Patients with active TED, characterised by ongoing inflammation, may have a higher tendency to bleed compared with those in the later stages of the disease, where inflammation is inactive. However, a subgroup analysis in the current study comparing acute decompression for patients with vision-threatening optical neuropathy (15 decompressions) and decompression for proptosis reduction (31 decompressions) revealed no difference in the amount of bleeding between the two groups, with both experiencing an average of 18.70 g of operative bleeding. On the other hand, the range demonstrated a tendency of more bleeding in the acute group at 18.70 g (10.40–46.75) compared with 18.70 g (6.54–33.70) in the reconstructive group. To fully evaluate the risk of increased bleeding in patients with active TED, a larger study would be needed.

The reduced perioperative bleeding observed in this study when using nasal packing during external medial orbital wall decompression might shorten the time of surgery due to enhanced visualisation and less time spent on suction and cauterisation. In this present study, the duration of the surgical procedure was not measured. However, de Lange et al reported a similar reduction in haemorrhage when cocaine-adrenaline was used, but no significant reduction in surgery duration.27 To evaluate the potential for shorter surgery duration in medial orbital wall decompressions, a study with a single surgeon and a much larger population than included in this study would be preferable. In addition, intraoperative bleeding may be influenced by the surgeon’s technical skills and their intraoperative management of haemorrhage. Nevertheless, interaction analysis and post hoc tests revealed no statistically significant crude differences between surgeons in this cohort.

In conclusion, the highly significant reduced haemorrhage during external orbital medial wall decompression when using preoperative nasal packing with cocaine-adrenaline is of great importance since even a slight reduction in haemorrhage leads to better visualisation. Nasal packing with a strong vasoconstrictive agent can thereby be an easy way to facilitate the surgical procedure and reduce the risk of complications.

Acknowledgements

We particularly thank all the surgical staff involved at St Erik Eye Hospital, Karolinska Institutet, Sweden.

Footnotes

Funding: This study was supported by the Karolinska Institute Foundation for Eye Research; the Elsy, Harry and Henrik Johansson Foundation; the Carmen and Bertil Regnér Foundation; and the Swedish Eye Foundation.

Data availability free text: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Patient consent for publication: Not applicable.

Ethics approval: This study involves human participants and was approved by the Swedish Ethical Review Authority (2022-00192-01). The study was conducted in accordance with the ethical guidelines of the Declaration of Helsinki as amended in October 2013. All subjects gave their written informed consent prior to inclusion in the study. Participants gave informed consent to participate in the study before taking part.

Provenance and peer review: Not commissioned; externally peer reviewed.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data availability statement

Data are available upon reasonable request.

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Data Availability Statement

Data are available upon reasonable request.

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