Would emergency medicine consultants be authorised and able to perform a lateral canthotomy in a sight threatening emergency.
Date First Published:
January 26, 2016
Last Updated:
February 11, 2016
Report by:
Dr Mukul Shah, Opthalmology SHO (Current post) also Emergency Medicine Registrar post MCEM (Lister Hospital, Stevenage)
Search checked by:
Dr Mukul Shah and Mr Stephen Campbell, Lister Hospital, Stevenage
Three-Part Question:
Could -an Emergency Medicine consultant or middle grade] [Perform a lateral canthotomy]
[To save the eye with a sight threatening Emergency]
Clinical Scenario:
You are a senior doctor working in the Emergency department when a patient presents with a red painful eye. You suspect orbital compartment syndrome and know the patient could lose their sight if you don't act. You know how to do a lateral canthotomy as well as the risks but wonder if it is reasonable to do this within the emergency department?
Search Strategy:
CochraneLateral Canthotomy and Emergency Medicine – no results.
Just lateral Canthotomy -3 results, nil relevant
PubMED/Medline
Lateral AND Canthotomy AND Emergency Medicine AND Consultant. = no results.
Lateral Canthotomy AND Emergency Medicine = 6 results ( 3 of which were relevant)
Just lateral Canthotomy -3 results, nil relevant
PubMED/Medline
Lateral AND Canthotomy AND Emergency Medicine AND Consultant. = no results.
Lateral Canthotomy AND Emergency Medicine = 6 results ( 3 of which were relevant)
Search Details:
3 relevant papers listed below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Orbital Compartment Syndrome: Alternative Tools to Perform a Lateral Canthotomy and Cantholysis Iserson KV, Luke-Blyden Z, Clemans S 12/11/2015 United States | Expert opinion by consultants based in US – no patients | expert opinion | Orbital compartment syndrome acutely threatens vision. Lateral canthotomy and cantholysis ameliorate the compartment syndrome and, to save a patient's vision, must be performed in a timely manner. This requires appropriate tools. In resource-poor settings, the straight hemostat and iris scissors that are generally used for this procedure may be unavailable. | In such situations, safe alternatives include using a multitool in place of a hemostat and a #11 scalpel blade instead of the iris scissors. As when using hemostats of varying sizes, the pressure applied to the multitool must be carefully modulated. When using a scalpel blade for the lateral canthotomy, the hemostat arm remains beneath the lateral canthus as a "backstop" to protect deeper tissues. For the cantholysis, use the back of the blade to "strum" for the ligaments, reversing its direction only to cut the ligament when it is identified. | low level of evidence. Due to rarity and ethical restrictions a cohort study or randomised controlled trial are not faesible but this is not even the next level of evidence (case report) and is simply the view of experts. |
| Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome Rowh AD, Ufberg JW, Chan TC, Vilke GM. Mar-15 United States | single case report | To present a case of orbital compartment syndrome caused by traumatic retrobulbar hemorrhage and the procedure of lateral canthotomy and cantholysis, reviewed with photographic illustration | Case report - Lateral canthotomy and cantholysis are readily performed at the bedside with simple instruments. The procedure may prevent irreversible blindness in cases of acute orbital compartment syndrome. | Emergency physicians should be familiar with lateral canthotomy and cantholysis in the management of orbital compartment syndrome to minimize the chance of irreversible visual loss. | weak level of evidence due to rarity. Only case report |
| Lateral canthotomy and cantholysis: a simple, vision-saving procedure McInnes G, Howes DW. Jan-02 Canada | Single case report - 4 37 Year old male |
The case of a 37-year-old man with blunt ocular trauma, a retrobulbar hemorrhage and rapidly increasing orbital pressure requiring an urgent lateral canthotomy and cantholysis is presented. Lateral canthotomy can be performed by ED senior staff in an emergency | Lateral canthotomy and cantholysis is a simple procedure that can be performed by emergency physicians. | It has the potential to save vision, particularly in cases of blunt ocular trauma. Succesful use of this in the case of this 37 year old gentleman described | Only a single case report due to rarity. hence weak level of evidence |
Author Commentary:
Both the case reports as well as the expert review suggest lateral canthotomy is a procedure that can be performed in the emergency department when a sight threatening situation arises. Due to ethical concerns it would not be possible to have a higher level of evidence for this question.
There are more papers and reviews in the opthalmology literature as opposed to the emergency medicine literature. However, this is not transferable as the environment and training of individuals concerned is very different.
As it is a rare outcome, multiple case report are the best level of evidence possible.
There are more papers and reviews in the opthalmology literature as opposed to the emergency medicine literature. However, this is not transferable as the environment and training of individuals concerned is very different.
As it is a rare outcome, multiple case report are the best level of evidence possible.
Bottom Line:
Case reports and expert review suggest lateral canthotomy can be done in the Emergency department in a sight threatening situation. More case reports in this area would be welcome. Particularly in the UK
References:
- Iserson KV, Luke-Blyden Z, Clemans S. Orbital Compartment Syndrome: Alternative Tools to Perform a Lateral Canthotomy and Cantholysis
- Rowh AD, Ufberg JW, Chan TC, Vilke GM. . Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome
- McInnes G, Howes DW.. Lateral canthotomy and cantholysis: a simple, vision-saving procedure