Canthotomy

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Background

  • Causes of acute orbital compartment syndrome (OCS)[1]
    • Trauma (retrobulbar hematoma) - most common cause
    • Spontaneous bleed
    • Tumor
    • Orbital cellulitis/abscess
    • Prolonged hypoxemia
  • OCS is a clinical diagnosis
    • Vision loss can be permanent after 60-100 min of ischemia[1] - do not delay procedure for imaging[2]

Indications[3]

  • Suspected acute orbital compartment syndrome (OCS), plus one or more of the following:
    • 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

  • Globe Rupture

Equipment

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

Procedure[1][3][4]

Consider sedating patient for procedure, if time allows

  • Prep and drape the area (Irrigation with normal saline is acceptable prep given emergent nature of procedure)
  • Inject lidocaine with epi 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)
  • 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 dissect bluntly until you palpate/visualize the lateral canthus tendon
  • 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 cut the superior crux of the tendon

Complications

  • iatrogenic globe/tendon/lacrimal duct injury
  • loss of adequate lower lid suspension
  • bleeding
  • infection
  • fibrosis
  • vision loss

See Also

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.
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