Lateral canthotomy (part 1) – recognition and making the decision

16 Jan
Raging hypothetical:
 
A 28 year old man presents to the ER after motor vehicle accident. He has sustained significant left sided facial trauma with periorbital ecchymosis and soft tissue swelling on the left side. He is complaining of eye pain and blurry vision but has no other complaints.
 
On exam the globe is adequately visualized and shows no signs of rupture. Unilateral proptosis is present, and the left eye is not reactive to light and all extraocular movements are diminished. Visual acuity is diminished on the left as well.
 
WHAT DOES THIS MEAN?
This patient is exibiting signs of orbital compression syndrome which means permanent vision loss is imminent.
 
In this case retroorbital hematoma due to trauma is filling the orbit with blood and displacing the globe. 
 
This results in proptosis as the globe is shifted anteriorly, but this movement is limited by the medial and lateral canthal ligaments
 
Once the eye is maximally displaced, intraorbital pressure increases until perfusion of vital ocular structures is affected and permanent vision loss results.
 
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What can we do about this?
Lateral canthotomy and cantholysis. This procedure releases the canthal ligament and allows the eye to be displaced superficially, releasing pressure on the globe and allowing for resumed perfusion of the eye and retina.
 
When is this indicated?
After significant trauma to the face, suspicion for ocular compression syndrome should be high. This procedure should be completed within 2 hours of symptom onset to prevent permanent damage.
 
Primary indications: In the appropriate clinical setting, unilateral vision loss, unilateral proptosis, and ocular pressure greater than 40 mm hg by tonometry are all indications for canthotomy.
 
Secondary indications:  Pupillary defect, cherry red macula, ophthalmoplegia, optic nerve pallor, painful eye.
 
Contraindication: Globe rupture.
 
Part 2 comes tomorrow… stay tuned for a quick hit procedure review for your next lateral canthotomy!
 
Submitted by Lee Cunningham.

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