Canthotomy: Difference between revisions

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==Indications==
==Background==
[[File:Schematic diagram of the human eye en.png|thumb|Eye anatomy.]]
*Acute [[Ocular compartment syndrome|orbital compartment syndrome]] (OCS) is a clinical diagnosis
*Vision loss can be permanent after 60-100 min of ischemia<ref name="JEM" /> - do not delay procedure for imaging<ref>Mohammadi F, Rashan A, Psaltis A, et al. Intraocular Pressure Changes in Emergent Surgical Decompression of Orbital Compartment Syndrome. JAMA Otolaryngol Head Neck Surg. 2015 Jun 1;141(6):562-5.</ref>


===Causes===
*Trauma ([[retrobulbar hematoma]]) - most common cause<ref name="JEM">Rowh AD, Ufberg JW, Chan TC, et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30.</ref>
*Spontaneous bleed
*Tumor
*[[Orbital cellulitis]]/abscess
*Prolonged [[hypoxemia]]


Indicated in pt with acute orbital compartment syndromeAbsolute indications:  
==Indications==
 
*Suspected acute orbital compartment syndrome (OCS), plus one or more of the following:<ref name="CJEM">McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002 Jan;4(1):49-52.</ref>
- acute loss of visual acuity
**Decreased visual acuity
 
**IOP >40 '''or''' marked difference in globe compressibility by palpation
- increased intraocular pressure (>40 mm Hg)
**Proptosis
 
- severe proptosis
 
- diffuse subconjunctival hemorrhage
 
- periorbital edema
 
Relative indications:
 
- afferent pupillary defect
 
- ophthalmoplegia


- cherry red macula
*Secondary indications (subjective and nonspecific) - if only secondary indications are present, get emergent ophthalmology consult prior to performing canthotomy.
**Afferent pupillary defect
**Cherry red macula
**Ophthalmoplegia
**Nerve head pallor
**Significant eye pain


- optic nerve pallor
==Contraindications==
 
*[[Globe rupture]]
- severe eye pain
 
- periorbital crepitus/edema
 
 
==Contraindications ==
 
 
globe rupture
 


==Equipment==
==Equipment==
 
*Betadine prep
 
*Sterile drape or towels
- Lidocaine w/epi
*[[Lidocaine]] with epi
 
**Syringe with 27-30ga needle
- sterile gloves, face shield, gown
*Normal saline for irrigation
 
*Straight hemostat or needle driver
- sterile field
*Iris or suture scissors
 
*Forceps
- syringe with 25 gauge needle
 
- normal saline for irrigation
 
- straight hemostat
 
- sterile iris or suture scissors
 
- forceps
 
- betadine/iodine prep
 


==Procedure==
==Procedure==
''Consider sedating patient for procedure, if time allows''<ref name="JEM" /><ref name="CJEM" /><ref name="Spec Ops">Ballard SR, Enzenauer RW, O'Donnell T, et al. Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital hemorrhage. J Spec Oper Med. 2009 Summer;9(3):26-32.</ref>
*Prep and drape the area (Irrigation with normal saline is acceptable prep given emergent nature of procedure)
*Inject lidocaine with epinephrine into the lateral canthus directing the needle tip toward the lateral orbital rim (away from the globe)
*Apply hemostat to the lateral canthus from the angle of the eye to the orbital rim and clamp shut for ~1 min. (provides relative devascularization as well as a landmark for the canthotomy)
*Using scissors, incise the lateral canthus from the angle of the eyelid to the orbital rim (~1cm).
*Retract the inferior lid and bluntly dissect tissue until the canthal tendon is identified.
*Perform inferior cantholysis - cut the inferior crus of the lateral canthus tendon (point scissors infero-posteriorally toward the lateral orbital rim, avoiding the globe)
*Recheck IOP → if still elevated, perform superior cantholysis - cut the superior crus of the canthal tendon (some experts recommend performing both inferior and superior cantholysis at the same time, prior to re-evaluating IOP)


 
===Signs of successful procedure===
1) consider sedating patient for procedure
*improved visual acuity
 
*resolution of afferent pupillary defect
2) prep and drape the area
*decrease in IOP to <40 mm Hg<ref>Scofi J. Lateral canthotomy. In: Shah K, Mason C, eds. Essential Emergency Procedures. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2015:(Ch) 17.</ref>
 
3) inject 1cc of lido with epi into the lateral canthus directing the needle tip toward the lateral orbital rim
 
4) irrigate eye to eliminate debris
 
5) crimp the skin at the lateral corner of the pts eye using a straight hemostat for ~1-2 minutes (make sure to crimp all the way down to the orbital rim)
 
6) lift up the skin around the lateral orbit with forceps and make a 1-2 cm cut with scissors beginning at the lateral corner of the eye and extending laterally
 
7) retract the inferior lid and dissect bluntly until you palpate/visualize the lateral canthus tendon
 
8) cut the inferior crux of the lateral canthus tendon (point scissors infero-posteriorally toward the lateral orbital rim avoiding the globe)
 
9) recheck IOP, if still elevated cut the superior crux of the tendon
 


==Complications==
==Complications==
*Incomplete cantholysis
*Iatrogenic globe or surrounding structure injury (rare)
*Loss of adequate lower lid suspension
*Bleeding
*Infection


==See Also==
*[[Orbital Hematoma]]
*[[Vertical lid split procedure]]


- iatrogenic globe/tendon/lacrimal duct injury
==External Links==
 
*EMRAP procedure video- https://www.youtube.com/watch?v=tgQaKVGynFA
- loss of adequate lower lid suspension
*Review article by Murali et al: Orbital compartment syndrome: Pearls and pitfalls for the emergency physician. JACEP Open. 2021; 2:e12372. https://doi.org/10.1002/emp2.12372
 
- bleeding
 
- infection
 
- fibrosis
 
- vision loss
 
 


==References==
<references/>


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Ophthalmology]]

Latest revision as of 14:53, 17 October 2024

Background

Eye anatomy.

Causes

Indications

  • Suspected acute orbital compartment syndrome (OCS), plus one or more of the following:[3]
    • Decreased visual acuity
    • IOP >40 or marked difference in globe compressibility by palpation
    • Proptosis
  • Secondary indications (subjective and nonspecific) - if only secondary indications are present, get emergent ophthalmology consult prior to performing canthotomy.
    • Afferent pupillary defect
    • Cherry red macula
    • Ophthalmoplegia
    • Nerve head pallor
    • Significant eye pain

Contraindications

Equipment

  • Betadine prep
  • Sterile drape or towels
  • Lidocaine with epi
    • Syringe with 27-30ga needle
  • Normal saline for irrigation
  • Straight hemostat or needle driver
  • Iris or suture scissors
  • Forceps

Procedure

Consider sedating patient for procedure, if time allows[1][3][4]

  • Prep and drape the area (Irrigation with normal saline is acceptable prep given emergent nature of procedure)
  • Inject lidocaine with epinephrine into the lateral canthus directing the needle tip toward the lateral orbital rim (away from the globe)
  • Apply hemostat to the lateral canthus from the angle of the eye to the orbital rim and clamp shut for ~1 min. (provides relative devascularization as well as a landmark for the canthotomy)
  • Using scissors, incise the lateral canthus from the angle of the eyelid to the orbital rim (~1cm).
  • Retract the inferior lid and bluntly dissect tissue until the canthal tendon is identified.
  • Perform inferior cantholysis - cut the inferior crus of the lateral canthus tendon (point scissors infero-posteriorally toward the lateral orbital rim, avoiding the globe)
  • Recheck IOP → if still elevated, perform superior cantholysis - cut the superior crus of the canthal tendon (some experts recommend performing both inferior and superior cantholysis at the same time, prior to re-evaluating IOP)

Signs of successful procedure

  • improved visual acuity
  • resolution of afferent pupillary defect
  • decrease in IOP to <40 mm Hg[5]

Complications

  • Incomplete cantholysis
  • Iatrogenic globe or surrounding structure injury (rare)
  • Loss of adequate lower lid suspension
  • Bleeding
  • Infection

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 Rowh AD, Ufberg JW, Chan TC, et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30.
  2. ↑ Mohammadi F, Rashan A, Psaltis A, et al. Intraocular Pressure Changes in Emergent Surgical Decompression of Orbital Compartment Syndrome. JAMA Otolaryngol Head Neck Surg. 2015 Jun 1;141(6):562-5.
  3. ↑ 3.0 3.1 McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002 Jan;4(1):49-52.
  4. ↑ Ballard SR, Enzenauer RW, O'Donnell T, et al. Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital hemorrhage. J Spec Oper Med. 2009 Summer;9(3):26-32.
  5. ↑ Scofi J. Lateral canthotomy. In: Shah K, Mason C, eds. Essential Emergency Procedures. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2015:(Ch) 17.
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