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 to lateral canthotomy
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.)
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.
Along this same path, cut all layers of tissue with the iris scissors.
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.
Other Lateral Canthotomy 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:
The Procedures Course: Orbital decompression – lateral canthotomy & cantholysis
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
Morgenstern, J. Lateral Canthotomy – procedure guide, First10EM, April 1, 2015. Available at:
https://doi.org/10.51684/FIRS.242
12 thoughts on “Lateral Canthotomy – procedure guide”
A few extra tips and resources are available here: http://adelaideemergencyphysicians.com/2014/01/a-nasty-black-eye-2/
Chlorhexidine shouldn’t be use next to the eye. Use half diluted betadine if potential for it to go into the eye
Hi Justin
Good write up.
One small point, I think its probably not evidence based… but.. some info here; https://journals.lww.com/dermatologicsurgery/Abstract/2017/01000/Chlorhexidine_Keratitis__Safety_of_Chlorhexidine.1.aspx
There is a theoretical risk of chlorhex in the eyes, we tend to opt for dilute betadine as a topical prep prior to eye procedures.
There are some very dilute chlorhex eye drops that are marketed but not the stuff we commonly splash around in the ED
Not a big change, but it seems a good choice if there is a potential risk and no real benefit of chlorhex.