Canthotomy: Difference between revisions
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== | ==Background== | ||
[[File:Canthotomy anatomy.jpeg|thumb|]] | |||
= | *Acute 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<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>=== | ||
*Trauma ([[retrobulbar hematoma]]) - most common cause | |||
*Spontaneous bleed | |||
*Tumor | |||
*[[Orbital cellulitis]]/abscess | |||
*Prolonged [[hypoxemia]] | |||
==Contraindications == | ==Indications<ref name="CJEM">McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002 Jan;4(1):49-52.</ref>== | ||
*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== | ==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<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>== | |||
'''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 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) | |||
==Complications== | ==Complications== | ||
*Incomplete cantholysis | |||
*Iatrogenic globe or surrounding structure injury (rare) | |||
*Loss of adequate lower lid suspension | |||
*Bleeding | |||
*Infection | |||
==See Also== | ==See Also== | ||
*[[Orbital Hematoma]] | *[[Orbital Hematoma]] | ||
==External Links== | |||
EMRAP procedure video- https://www.youtube.com/watch?v=tgQaKVGynFA | |||
==References== | |||
<references/> | |||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category: | [[Category:Ophthalmology]] |
Revision as of 02:50, 23 August 2019
Background
- Acute orbital compartment syndrome (OCS) is a clinical diagnosis
- Vision loss can be permanent after 60-100 min of ischemia[1] - do not delay procedure for imaging[2]
Causes[1]
- Trauma (retrobulbar hematoma) - most common cause
- Spontaneous bleed
- Tumor
- Orbital cellulitis/abscess
- Prolonged hypoxemia
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 with 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 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)
Complications
- Incomplete cantholysis
- Iatrogenic globe or surrounding structure injury (rare)
- Loss of adequate lower lid suspension
- Bleeding
- Infection
See Also
External Links
EMRAP procedure video- https://www.youtube.com/watch?v=tgQaKVGynFA
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 3.1 McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002 Jan;4(1):49-52.
- ↑ 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.