what is lateral canthotomy

Lateral canthotomy, the emergency treatment for orbital compartment syndrome, is the surgical exposure of the lateral canthal tendon. Cantholysis is canthotomy plus incision of the inferior branch (crus) of the tendon.

Full Answer

How does a lateral Canthotomy work?

Relevant Anatomy for Lateral Canthotomy The lateral canthal tendon has two branches: a superior and an inferior. Cutting one, or both, loosens the eyelids and allows the globe to expand out of the orbit and thus relieve pressure on the eye.

When do you do a lateral Canthotomy?

Indications for immediate canthotomy include sudden vision loss or relative afferent pupillary defect in the setting of retrobulbar hemorrhage with proptosis and IOP greater than 40 mm Hg.

What does canthotomy mean in medical terms?

Description. Canthotomy is an operation for lengthening the palpebral fissure by incision through the lateral canthus or for restoration of the canthus. This policy describes the medical necessity requirements for canthotomy.

What is lateral Cantholysis?

Lateral canthotomy, the emergency treatment for orbital compartment syndrome, is the surgical exposure of the lateral canthal tendon. Cantholysis is canthotomy plus incision of the inferior branch (crus) of the tendon.

Do I need lateral Canthoplasty?

Lateral canthoplasty is an ideal procedure for certain candidates, who may have eyes with a very pleasing crease, but may still lack an attractive facial appearance because of the unpleasant lateral tilt. The procedure is typically performed together with double eyelid surgery.

What causes orbital compartment syndrome?

Causes of OCS: OCS primarily occurs due to hemorrhage, abscess, tumor, orbital edema or emphysema, orbital cellulitis, retrobulbar injection, or preexisting medical disorders (5).

What is the normal IOP?

Measuring Eye Pressure Normal eye pressure ranges from 12-21 mm Hg, and eye pressure of greater than 21 mm Hg is considered higher than normal. When the IOP is higher than normal but the person does not show signs of glaucoma, this is referred to as ocular hypertension.

What is lateral canthus?

Lateral canthus: the lateral confluence of upper and lower eyelid margins. Sclera: the collagenous outer wall of the eyeball.

What does STL stand for medical?

sublinguallySL. sublingually, under the tongue.

What is the lateral canthal angle?

The lateral canthus is the point where the outer edge of the upper and lower eyelids meet. These two structures join to form an angle. Rounding or blunting of this angle may occur after previous eyelid surgery or with aging.

What is lateral Canthopexy?

Lateral canthoplasty is a procedure in which the lateral canthus is fixed (anchored) to the lateral orbital rim after surgical division (lateral cantholysis). It is usually performed with lower blepharoplasty in order to correct the laxity and malposition of the lower lid [1].

Who needs orbital decompression surgery?

Orbital decompression surgery is performed to relieve exophthalmos, a condition associated with Graves' disease, which causes the eyes to bulge and may lead to loss of vision.

Who needs Orbital decompression surgery?

Orbital decompression surgery is performed to relieve exophthalmos, a condition associated with Graves' disease, which causes the eyes to bulge and may lead to loss of vision.

What is the function of the lateral canthus?

The lateral canthal tendon is attached to the inner aspect of the frontozygomatic process on the orbital osseous tubercle and is essential to the structural fixation of the lateral canthus as well as a check on the mobility of the lateral canthal angle of the eye itself.

What is the lateral canthus of the eye?

The outer corner of the eyelids where the upper and lower eyelids meet are rounded instead of joining in a discrete angle. This area is called the outer canthus or the lateral canthus.

How does Orbital decompression surgery work?

Decompression surgery works by expanding the area of the eye socket by removing sections of the eye socket bone. This allows the swollen tissue to fall into the expanded areas, giving space for the eye to fall back into a more normal position.

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.

Other Lateral Canthotomy FOAMed Resources

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

What is canthotomy for orbital compartment syndrome?

Lateral canthotomy, the emergency treatment for orbital compartment syndrome, is the surgical exposure of the lateral canthal tendon. Cantholysis is canthotomy plus incision of the inferior branch (crus) of the tendon.

What is canthotomy lateral?

How to do Lateral Canthotomy. Lateral canthotomy, the emergency treatment for orbital compartment syndrome, is the surgical exposure of the lateral canthal tendon. Cantholysis is canthotomy plus incision of the inferior branch (crus) of the tendon.

Why does intraocular pressure increase?

Because the eye is constrained by the lids and the orbit, increased intraorbital pressure can cause intraocular pressure to rise rapidly and compress the optic nerve and its vascular supply. Untreated, this increased pressure causes permanent vision loss (OCS). Lateral canthotomy and cantholysis are done immediately to relieve intraorbital pressure ...

How to treat a lateral canthal incision?

Drape the area. Inject 1 or 2 mL of local anesthetic containing epinephrine into the lateral canthal incision site.

What to do if your eye tendon is still intact?

If the tendon is still intact, cut it. Cutting the tendon loosens the eyelid and relieves pressure on the eye even more.

What are the complications of lateral canthotomy?

Complications of Lateral Canthotomy. Complications may include. Mechanical damage of the eye (eg, to the lateral rectus muscle, lacrimal gland, or lacrimal artery) or lids. Hemorrhage. Infection.

How long to crush canthus?

Use a needle driver or hemostat to crush the tissue from the lateral canthus to the rim of the orbit, for about 20 sec to 2 min. Crushing this tissue helps minimize bleeding and makes it easier to see where to cut when there is extensive traumatic edema.

What is the orbital compartment?

The orbital compartment is a fixed space with limited capacity for expansion. If something like blood fills part of that space the pressure increases and may result in ischaemia of the optic nerve or the retina. A lateral canthotomy is a way of releasing this pressure.

What is the normal pressure for a canthotomy?

Usually if the pressures are <30mmHg, medical management is acceptable, however when the pressures reach 40 mmHg, there is a need for immediate decompression by lateral canthotomy and cantholysis.

How long to devascularize canthus?

Devascularise the Lateral Canthus: Use a small clamp to clamp the tissues for about 15-30 seconds.

How long does it take for vision loss to occur?

You have up to approximately 2 hours before irreversible visual loss occurs. It may occur in less than 2 hours however, so speed is of the essence.

Can eye pressure be controlled?

There may be some bleeding, however this is easily controlled by direct pressure. The eye pressure should reduce almost immediately.

Is a potential globe rupture contraindicated?

A Potential Globe Rupture is the main contraindication. Findings that might point to that include:

Is retrobulbar haematoma an ophthalmological emergency?

This is an ophthalmological emergency. In perfect world, the treatment should occur first, however because we did not know what was happening a rapid CT was done, which demonstrated a retrobulbar haematoma, causing the proptosis and a stretching of the optic nerve.

What is the best example of lateral canthal tendon?

Eyelid procedures. Many common non-emergent eyelid surgeries also require a lateral canthotomy and cantholysis. The best example is the lateral tarsal strip. In this case the lateral canthal tendon is released and a new, shorter "lateral canthal tendon" is formed by anchoring the tarsus to the periosteum of the orbital rim.

How does cantholysis help the globe?

Releasing the lateral canthal tendon from the orbital rim by performing a lateral canthotomy and cantholysis allows for more anterior displacement of the globe, leading to a reduction in intraorbital pressure and a return of optic nerve and retinal circulation.

What is lateral canthotomy?

The ability to perform a lateral canthotomy and cantholysis is an essential skill for every ophthalmologist and emergency room physician. It can be a vision-saving technique in the setting of decreased perfusion to the optic nerve or globe as a result of increased orbital pressure. In addition, it is a useful step in many common eyelid procedures.

What causes anterior displacement of the globe?

Increased orbital pressure can cause the anterior displacement of the globe which manifests clinically as proptosis. The anterior displacement of the globe is limited by the eyelid complex which is anchored to the orbital rim primarily by the lateral and medial canthal tendons.

What is the lateral wall of a sphenoid?

The lateral wall is composed of the zygomatic and greater wing of the sphenoid.

What is the roof of the orbit?

The orbit consists of four bony walls within the skull which angle posteriorly to form a cone: The roof is composed of the frontal and lesser wing of the sphenoid bone. The medial wall is composed of the ethmoid, lacrimal, maxillary, and sphenoid bones. The floor is composed of the maxillary, palatine and zygomatic bones.

How can intraorbital pressure be assessed?

Intraorbital pressure can be indirectly assessed by measuring intraocular pressure.

Why do they do lateral canthotomy?

The lateral canthotomy can be performed bedside to quickly reduce intraocular pressure. Most commonly, it is performed due to trauma causing a retrobulbar hemorrhage, resulting in orbital compartment syndrome (OCS). Prolonged intraocular pressures cause ischemia of the optic nerve and retina.

When is lateral canthotomy recommended?

However, lateral canthotomy is advised when there is increased intraocular pressures, proptosis, and a tense globe in the setting of an appropriate clinical picture. Thus, just because the patient does not yet have severe vision loss, it does not mean one should continue to wait and observe. [2]

How long does it take for vision to recover from ischemia?

[1] It is important to remember there can be a delay in the recovery of vision up to 4 weeks after intervention.

What is the stopping point of a lateral orbit?

The stopping point is when you have cut a clear path without tissue blocking the path to the lateral orbit

Can OCS be made based on clinical exam?

OCS can and should be made based on clinical exam only, however two imaging modalities are available as adjuncts.

How to perform inferior cantholysis?

Perform inferior cantholysis - cut the inferior crus of the lateral canthus tendon (point scissors infero-posteriorally toward the lateral orbital rim, avoiding the globe)

How long to clamp lateral canthus?

Apply hemostat to the lateral canthus from the angle of the eye to the orbital rim and clamp shut for ~1 min. (provides relative devascularization as well as a landmark for the canthotomy)

How long does it take for vision to go away after ischemia?

Vision loss can be permanent after 60-100 min of ischemia - do not delay procedure for imaging

What is acceptable prep given emergent nature of procedure?

Prep and drape the area (Irrigation with normal saline is acceptable prep given emergent nature of procedure)

What is a canthus?

1. An operation for lengthening the palpebral fissure by incision through the lateral canthus. 2. An operation for restoration of the canthus. [G. kanthos, canthus, + tomē, incision] Farlex Partner Medical Dictionary © Farlex 2012.

What surgical procedure was used to treat proptosis?

Clinical examination revealed proptosis which was surgically managed by lateral canthotomyfollowed by temporary tarsorrhaphy.

What is the treatment for orbital emphysema?

The treatment in case of orbital emphysema accompanied by increasing symptoms (especially deterioration of vision) should include one of the procedures: lateral canthotomy, inferior and/or superior cantholysis, orbital decompression, or simple puncture of the air vessel which may prevent the patient from blindness [11, 12, 15, 19].

What gauge needle is used for canthotomy?

Lateral canthotomywas performed and the anterior chamber was cannulated medially at the limbus with a 30-gauge needle (Fig 1) connected to a system consisting of a pressure monitoring kit (Transpac IV Monitoring Kit; ICU Medical Inc, San Clemente, CA, USA) with a transducer, polyethylene tubes, monitoring cable (Transpac Reusable Cable; Hospira Inc, Lake Forest, IL, USA), and a monitor (CARESCAPE Monitor B650; GE Healthcare Finland Oy, Finland).

What is a slit on a canthusso?

Slitting of the CANTHUSso as to widen the lid opening.

How long does it take to perform lateral canthotomy?

Computed tomography is commonly used to further evaluate the orbits as it is often immediately available unlike magnetic resonance imaging which often cannot be obtained in a timely manner.[30] Lateral canthotomyis regarded as a first-line intervention for decompression of the orbit in OCS,[31] and preferably, it should be performed within an hour or 2 h as it was suggested by some authors.[28],[29] Immediate lateral canthotomyand inferior cantholysis are recommended to prevent visual loss owing to optic nerve compression in OCS.

Can orbital hematoma be treated with decompression?

Orbital hematoma is oftentimes obvious to recognize on physical examination by rapid unilateral orbital swelling and thus is easily treated with decompression (i.e., lateral canthotomyand cantholysis).

Case

Equipment

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 c...

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Other Lateral Canthotomy Foamed Resources

References