Procedure: Lateral Canthotomy

A simplified approach to the initial assessment and management of emergency department patients with retro-orbital hematoma requiring emergent lateral canthotomy

Case

A 21 year old man was minding his own business on a street corner, when out of nowhere two dudes just jumped him. His primary injury appears to be to his right eye. He is complaining of a lot of eye pain and blurred vision. On exam, you note proptosis and an afferent pupillary defect. The opthamologist is covering at another hospital and is at least an hour away, but suggests you go ahead with the lateral canthotomy…

Equipment

  • Chlorhexadine
  • Lidocaine (with epi)
  • Needle and syringe for lidocaine injection
  • Straight mosquito hemostat
  • Iris scissors
  • Forceps

 

My approach

Explain the risks and benefits.

Consider sedation as required.

Clean the skin with chorhexadine.

Inject local anesthetic from the lateral canthus to the orbital rim. (Ignore the needle in the picture – direct the needle tip away from the globe.)

Lateral canthotomy step 1

Irrigate the eye with saline to clear any debris.

Slide a straight mosquito hemostat along the lateral canthus, with one prong against the orbit and the other superficial to the skin. Compress this tissue for 1 minute to minimize bleeding.

Lateral canthotomy step 2

Along this same path, cut all layers of tissue with the iris scissors.

Lateral canthotomy step 3

Grasp the lower eyelid with forceps and retract it to reveal the lateral canthal tendon. (The tendon is just inferior and posterior to the lateral canthal fold.)

Cut completely through the middle of the lateral canthal ligament with the iris scissors.

Lateral canthotomy step 4

 

 

Other FOAMed Resources

The the whole process in a series of excellent, short cadaver videos: Lateral Canthotomy and Cantholysis at wikemerg.ca

Bashed, Blind and Bulging aka Ophthalmology Befuddler 033 at LITFL

A great video from EMRAP and Jess Mason:

References

Bayram JD and Uwaydat SH. Lateral Canthotomy and Cantholysis or Acute Orbital Compartment Syndrome Management. In: Reichman EF (ed). Emergency Medicine Procedures, 2e. Toronto: McGraw-Hill; 2013.

MInnes G and Howes D. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002;4(1):49-52. At: http://www.cjem-online.ca/v4/n1/p49

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

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