Canthotomy

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]

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

EMRAP procedure video- https://www.youtube.com/watch?v=tgQaKVGynFA

References
  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. 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. 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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