Canthotomy: Difference between revisions

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==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]]
==Indications==
==Indications==
Indicated in pt with acute orbital compartment syndrome
*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>
**Decreased visual acuity
**IOP >40 '''or''' marked difference in globe compressibility by palpation
**Proptosis


===Absolute indications<ref>Rowh, AD, et al. Lateral Canthotomy and Cantholysis: Emergency Management of Orbital Compartment Syndrome. Journal of Emergency Medicine. 2014; S0736-4679(14)01222-0. http://dx.doi.org/10.1016/j.jemermed.2014.11.002</ref>===
*Secondary indications (subjective and nonspecific) - if only secondary indications are present, get emergent ophthalmology consult prior to performing canthotomy.
# acute loss of visual acuity
**Afferent pupillary defect
# increased intraocular pressure (>40 mm Hg)
**Cherry red macula
# severe proptosis
**Ophthalmoplegia
# diffuse subconjunctival hemorrhage
**Nerve head pallor
# periorbital edema
**Significant eye pain
# retrobulbar hemorrhage with afferent pupillary defect or restriction of eye movemeents


===Relative indications===
==Contraindications==
# afferent pupillary defect
*[[Globe rupture]]
# ophthalmoplegia
# cherry red macula
# optic nerve pallor
# severe eye pain
# periorbital crepitus/edema
 
==Contraindications ==
globe rupture


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


==Procedure==
==Procedure==
# consider sedating patient for 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
*Prep and drape the area (Irrigation with normal saline is acceptable prep given emergent nature of procedure)
# inject 1cc of lido with epi into the lateral canthus directing the needle tip toward the lateral orbital rim
*Inject lidocaine with epinephrine into the lateral canthus directing the needle tip toward the lateral orbital rim (away from the globe)
# irrigate eye to eliminate debris
*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)
# 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)
*Using scissors, incise the lateral canthus from the angle of the eyelid to the orbital rim (~1cm).
# 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
*Retract the inferior lid and bluntly dissect tissue until the canthal tendon is identified.
# retract the inferior lid and dissect bluntly until you palpate/visualize the lateral canthus tendon
*Perform inferior cantholysis - cut the inferior crus of the lateral canthus tendon (point scissors infero-posteriorally toward the lateral orbital rim, avoiding the globe)
# cut the inferior crux 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)
# recheck IOP, if still elevated cut the superior crux of the tendon
 
===Signs of successful procedure===
*improved visual acuity
*resolution of afferent pupillary defect
*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>


==Complications==
==Complications==
# iatrogenic globe/tendon/lacrimal duct injury
*Incomplete cantholysis
# loss of adequate lower lid suspension
*Iatrogenic globe or surrounding structure injury (rare)
# bleeding
*Loss of adequate lower lid suspension
# infection
*Bleeding
# fibrosis
*Infection
# vision loss


==See Also==
==See Also==
*[[Orbital Hematoma]]
*[[Orbital Hematoma]]
*[[Vertical lid split procedure]]
==External Links==
*EMRAP procedure video- https://www.youtube.com/watch?v=tgQaKVGynFA
*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


==Sources==
==References==
<references/>
<references/>


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Ophtho]]
[[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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