Morning Report: Lateral Canthotomy

Today’s Morning Report is presented by Dr. Corburn!

Following blunt facial trauma, a 35 year old patient is noted to have marked proptosis, restricted ocular movement, and decreased visual acuity of the left eye. What is the recommended temporizing maneuver?

Anterior chamber paracentesis
Carbon inhalation
Globe massage
Lateral canthotomy
None of the above

Lateral Canthotomy

Indications: Orbital compartment syndrome (retrobulbar hematoma with vision loss, proptosis, and/or elevated IOP…if patient is unconscious and you suspect and IOP>40mmHg, consider lateral canthotomy)

Signs/symptoms: Orbital pain, decreased visual acuity, diplopia, limited EOM, proptosis, increased IOP, ecchymosis, affect pupillary defect

Importance: Increased orbital pressure for as little as 90-120 minutes can cause irreversible blindness (retinal ischemia)

Etiology: Retrobulbar hemorrhage (spontaneous or secondary-trauma, anticoagulation, recent surgery, or anesthesia)

Contraindications: Globe rupture

Procedure:

-Anesthesia: Inject lidocaine into the lateral canthus directed toward the lateral orbital rim (1% or 2% with epi); you do not want the patient moving, may need conscious sedation or a very cooperative patient

-Crimp the skin of the lateral canthus using a hemostat for 1-2 minutes in order to achieve hemostasis

-Use scissors to make a lateral cut starting from the lateral corner of the eye, about 1-2cm in length

*this step alone is generally not sufficient to decrease enough orbital pressure, proceed to the next steps

-Pull down the inferior eyelid to expose the lateral canthus tendon

-Dissect out the inferior crux of the lateral canthus tendon

-Point scissors away from globe and cut the inferior crux of the lateral canthus tendon

-If IOP remains >40mmHg, dissect superiorly along the lateral rim and cut the superior crux of the lateral canthus tendon

Resources:

Liu, L, et al. Lateral Orbital Canthotomy. Medscape. March 2014. Accessed October 2014 <http://emedicine.medscape.com/article/82812-overview>

Spitalnic, S. Eye Emergencies: Review Questions. Self Assessment in Emergency Medicine, Hospital Physician. Feb 2005; 27-28.