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Eyes - Lateral canthotomy and cantholysis

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Indications

Suspected orbital compartment syndrome (pain, proptosis, raised IOP >40mmHg)

and

Evidence of retinal dysfunction (visual loss or relative afferent pupillary defect)

Contraindications (absolute in bold)

Suspected globe rupture (globe laceration, irregular pupil, hyphaemia)

Alternatives

None

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Failure (incomplete cantholysis)

Globe injury

Lacrimal artery, gland and muscular injury

Bleeding

Infection

Procedural hygiene

Standard precautions

Surgical aseptic non-touch technique

PPE: sterile gloves and gown, surgical mask, eye protection

Area

Any bed space

Staff

Procedural clinician and assistant

Equipment

5ml syringe with 25g needle for infiltration

Straight haemostat

Tissue forceps x 2

Suture scissors

Positioning

Supine

Medication

Amethocaine 0.5-1% drops

5ml lignocaine 1-2% with adrenaline (1:100,000)

Sequence

Apply 1-2 drops of amethocaine to affected eye

Inject 1-2ml of lignocaine with adrenaline into the lateral canthus directing needle tip away from the globe

Irrigate eye with normal saline to clear debris

Crimp lateral canthus with haemostat to the orbital rim for one minute, then remove

Incise 1cm with scissors from lateral corner of the eye extending laterally outward to orbital rim

Retract the inferior eyelid with forceps and identify the inferior crus of the lateral canthal tendon

Incise inferior crus of the lateral canthal tendon infero-posteriorally with scissors (cantholysis)

Reassess eye for improvement in visual acuity, resolution of RAPD, with IOP <40mmHg

If no improvement, confirm cantholysis (lower eyelid freely mobile, no tendon palpable with forceps), then

Proceed to divide the superior crus of the lateral canthal tendon

Post-procedure care

Apply moist gauze dressing

Urgent ophthalmology discussion and review

Reassess visual acuity and RAPD after 30 minutes

Provide analgesia

Document (completion, technique and complications)

Tips

This is a sight saving procedure with easily repairable incisions, do not hesitate if it is indicated

Do not delay for imaging, visual loss may become permanent within 60 minutes of retinal ischaemia

Discussion

Ophthalmoplegia is sometimes listed as a sign of raised intraocular pressure and hence an indication. However, it also a sign of globe rupture and hence may also suggest a contraindication. We have not included this sign in our guide.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Gardiner MF. Approach to eye injuries in the emergency department. In: UpToDate. Waltham (MA): UpToDate. 2020 Jan 14. Available from: https://www.uptodate.com/contents/approach-to-eye-injuries-in-the-emergency-department

Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015;48(3):325-330. doi:10.1016/j.jemermed.2014.11.002

Ballard SR, Enzenauer RW, O'Donnell T, Fleming JC, Risk G, Waite AN. Emergency lateral canthotomy and cantholysis: a simple procedure to preserve vision from sight threatening orbital hemorrhage. J Spec Oper Med. 2009;9(3):26-32.

McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002;4(1):49-52. doi:10.1017/s1481803500006060

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;141(6):562-565. doi:10.1001/jamaoto.2015.0524

Rixen J, Verdick R, Allen RC, Carter KD. Lateral canthotomy and cantholysis. Eyerounds.org. Iowa City, IA: University of Iowa Healthcare; 2013. Available from: https://eyerounds.org/tutorials/lateral-canthotomy-cantholysis.htm

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