Lateral Canthotomy and Cantholysis

 

Introduction

Lateral canthotomy and cantholysis (LCC) is a simple procedure used to decompress a compartment syndrome of the orbit.  It is most often used in cases of blunt trauma, when bleeding into the retrobulbar space cuases an increase in pressure resulting in ischemia to the retina and optic nerve1. LCC can be easily preformed by the emergency physician, and has the potential to save the patient’s vision. In this learning module

Indications  (DIP A CONE)

Primary indications

  • Decreased visual acuity
  • Intraocular pressure > 40 mmHg
  • Proptosis

Secondary Indications

  • Afferent pupillary defect
  • Cherry red macula
  • Ophthalmoplegia
  • Nerve head pallor
  • Eye pain

Contraindications

  • Globe rupture

The Procedure

Equipment required to perform LCC

  1. Lidocaine with epinephrine
  2. Syringe with 25 gauge 5/8 needle
  3. Hemostat or needle driver
  4. Iris or suture scissors
  5.  Forceps

Step 1

Clear debris and secretions away from the lateral canthus and prep surrounding skin with normal saline to improve visualization and reduce infection risk. (Video Clip 1) If patient is awake, have assistant stabilize the patient’s head  (and neck if any concern about c-spine injury exists).  Although  LCC is no more painful than laceration repair it can be visually disturbing for the patient.

Step 2

Inject 1-2 cc of Local anesthetic with epinephrine into the lateral canthus. This provides both pain relief and hemostasis at the time of devascularization and incision (Video Clip 2).

Step 3

Apply a hemostat or needle driver from the lateral canthus towards the bony orbit to devascularize the area for 30-90 seconds (Video Clip 3).

Step 4

Remove the devascularizing instrument and cut the demarcated area laterally 1-2cm in length (Video Clip 4).

 

Step 5

Using the forceps, pull the lower lid down to visualize the inferior canthal tendon (Video Clip 5a) and cut through this tendon (Video Clip 5b).

 

Step 6

After the inferior canthal tendon has been cut, reassess intraocular pressure with a tonometer. If the IOP remains >40mmHg, then decompression is inadequate. Lift the upper lid and also sever the superior lateral canthal tendon (Figure X).

Consultation and follow-up

Ideally, an ophthalmologist would be present to assess patients with orbital trauma when they present to the ED, but this is rare. Whenever possible, in cases of suspected retinal ischemia, emergency physicians should rapidly involve ophthalmology consultants.  "Time is ________" applies to the retina as much as it does to the heart or brain. Decrased time to reprerfusion leads to better outcomes.  The retina may tolerate approximately 2 hours of ischemia before the potential to recover normal vision is lost2, however this is based on expert opinion only and hence variation exists.  Whether ophthalmology is available at the time of LCC or not, any patient who has had a LCC in the ED required ophthalmology follow-up and ongoing treatment. 

 

References

1. Linden JA, Renner GS. Trauma to the globe. Emerg Med Clin North Am 1995;13(3):581-605.

2. Larsen M, Wieslander S. Acute orbital compartment syndrome after lateral blow-out fracture effectively relieved by lateral cantholysis. Acta Ophthalmol Scand 1999;77:232-3.

CLICK HERE FOR THE FULL ARTICLE OF THIS PROCEDURE WITH CASE STUDY

 

 

 

 

 

 

 

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2nd edit

oct 25 2223hrs

1950hrs oct 26,2011

Post 2 videos uploaded oct 26th

Video steps uploaded

WITH REFERENCES

revising video tags

Nov 13

Nov 13 vidio finish , just need pics to be scanned

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