Can Emergency Physicians Do Lateral Canthotomy?

July 11, 2023

Written by Gabby Leonard

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This retrospective study showed that EM providers are equipped to perform lateral canthotomy and cantholysis (C&C) in cases of orbital compartment syndrome (OCS) with success rates comparable to ophthalmologists.

Strum those chords!
Orbital compartment syndrome, typically in the setting of trauma, is a vision-threatening condition that requires rapid recognition and intervention by emergency medicine providers.

What is orbital compartment syndrome? It’s essentially a buildup of pressure in the orbit, typically from blood accumulation in the setting of trauma, leading to compression and ischemia of the optic nerve and vessels, which can cause permanent vision loss. The orbital compartment, like the skull, has a finite amount of space and is bordered by the orbital bones as well as orbital septum and canthal ligaments. In cases of orbital fractures, breach of this enclosed space may help decompress OCS and are typically associated with improved visual outcomes.

This study looked at first attempt success rates of C&C, defined as decrease in intraocular pressure to <30mmHg when performed by EM providers compared to ophthalmologists. Of the 74 eyes with suspected OCS, 50 eyes had procedural intervention by EM providers compared to 24 eyes intervened on by ophthalmologists. Notably there was no significant difference in first attempt success rates (68% EM vs. 79.2% ophthalmology, p=0.413). There were 16 eyes who had initial failure of C&C by EM providers and of these, 15 achieved successful decrease in IOP upon revision. 14/15 of these revisions were done by ophthalmologists.

Final visual acuity was worse when successful C&C was delayed due to multiple attempts. Additionally, this study shows that initial success rates of C&C are roughly 70-80% and should encourage providers to perform this procedure when OCS is suspected without delaying care.

How will this change my practice?
It is important to have a high suspicion and low threshold for treatment of OCS via lateral C&C. There are few contraindications (suspected globe rupture is the main one), and benefits far outweigh risks of performing this to save someone’s vision. Be generous with anxiolysis and cut further than you think (1-2cm) on initial incision. EM providers require dedicated training for this procedure and should also be trained in additional procedures such as vertical lid split which was shown to be non-inferior to C&C by Elpers et al. (18).

Source
Success rates of lateral canthotomy and cantholysis for treatment of orbital compartment syndrome. Am J Emerg Med. 2023 Jun 1;70:140-143. doi: 10.1016/j.ajem.2023.05.037. Epub ahead of print.

Works Cited

• EM:RAP. (2016, March 31). How perform a lateral canthotomy [Video]. https://www.youtube.com/watch?v=tgQaKVGynFA
• McCallum E, Keren S, Lapira M, Norris JH. Orbital Compartment Syndrome: An Update With Review Of The Literature. Clin Ophthalmol. 2019 Nov 7;13:2189-2194. doi: 10.2147/OPTH.S180058. PMID: 31806931; PMCID: PMC6844234.
• Elpers J, Areephanthu C, Timoney PJ, Nunery WR, Lee HBH, Fu R. Efficacy of vertical lid split versus lateral canthotomy and cantholysis in the management of orbital compartment syndrome. Orbit. 2021;40(3):222-7. https://doi.org/10.1080/01676830.2020.1767154. [Epub 2020 May 27. PMID: 32460574].