Today’s Morning Report is presented by Dr. Corburn!
Following blunt facial trauma, a 35 year old patient is noted to have marked proptosis, restricted ocular movement, and decreased visual acuity of the left eye. What is the recommended temporizing maneuver?
- Anterior chamber paracentesis
- Carbon inhalation
- Globe massage
- Lateral canthotomy
- None of the above
Lateral Canthotomy
Indications: Orbital compartment syndrome (retrobulbar hematoma with vision loss, proptosis, and/or elevated IOP…if patient is unconscious and you suspect and IOP>40mmHg, consider lateral canthotomy)
Signs/symptoms: Orbital pain, decreased visual acuity, diplopia, limited EOM, proptosis, increased IOP, ecchymosis, affect pupillary defect
Importance: Increased orbital pressure for as little as 90-120 minutes can cause irreversible blindness (retinal ischemia)
Etiology: Retrobulbar hemorrhage (spontaneous or secondary-trauma, anticoagulation, recent surgery, or anesthesia)
Contraindications: Globe rupture
Procedure:
-Anesthesia: Inject lidocaine into the lateral canthus directed toward the lateral orbital rim (1% or 2% with epi); you do not want the patient moving, may need conscious sedation or a very cooperative patient
-Crimp the skin of the lateral canthus using a hemostat for 1-2 minutes in order to achieve hemostasis
-Use scissors to make a lateral cut starting from the lateral corner of the eye, about 1-2cm in length
*this step alone is generally not sufficient to decrease enough orbital pressure, proceed to the next steps
-Pull down the inferior eyelid to expose the lateral canthus tendon
-Dissect out the inferior crux of the lateral canthus tendon
-Point scissors away from globe and cut the inferior crux of the lateral canthus tendon
-If IOP remains >40mmHg, dissect superiorly along the lateral rim and cut the superior crux of the lateral canthus tendon
Resources:
Liu, L, et al. Lateral Orbital Canthotomy. Medscape. March 2014. Accessed October 2014 <http://emedicine.medscape.com/article/82812-overview>
Spitalnic, S. Eye Emergencies: Review Questions. Self Assessment in Emergency Medicine, Hospital Physician. Feb 2005; 27-28.
Jay Khadpe MD
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