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

Indications[2]

  • 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/Iodine prep
  • Lidocaine w/epi
    • Syringe with 27-30ga needle
  • Sterile gloves, face shield, gown
  • Sterile drape or towels
  • Normal saline for irrigation
  • Straight hemostat
  • Sterile iris or suture scissors
  • Forceps

Procedure

Consider sedating patient for procedure

  • prep and drape the area
  • inject 1cc of lidocaine with epi into the lateral canthus directing the needle tip toward the lateral orbital rim
  • irrigate eye to eliminate debris
  • 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)
  • 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 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. ↑ McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002 Jan;4(1):49-52.
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