Please consider updating the video for how to perform a lateral canthotomy and cantholysis. The technique shown is incorrect/incomplete, and people following it will likely not get an adequate decrease in IOP. You have to pull the lower lid anteriorly to put tension on the inferior tendon to feel the "strum," and the tendon is not that far down into the orbit. When done correctly, the lower lid should easily flop down/out, which is not shown in the final photo at the end of the video.
There are videos of the procedure available on YouTube done by ophtalmology/oculoplastics that better show how to do the cantholysis and how distractible the lower lid should be when it's done:
Thanks for sharing your tips. Those are good videos for reference as well. Ultimately what matters is the repeat IOP. If it went down then the end goal was achieved, and that is stated in the video. If I get footage clarifying this specific technique I can add it to the video. Thanks again.
The language seems to imply that if a retrobulbar hematoma is present then there is by definition a compartment syndrome. However, as optho has informed me in the past, if lateral canthotomy fails the next step they take is breaking the bones of the compartment. Since many of these patient present with those bones are already blown out, the compartment pressures may not become elevated. I have seen patients with a hematoma that have had normal eye pressures and optho has chosen to follow without the lateral canthotomy being done. Curious if this sounds reasonable to you or are they just taking an unnecessary risk not doing it, or having me do it?
Thank you for your question! You bring up an important point: Bleeding behind the eye doesn't *always* lead to a compartment syndrome, but that is the feared complication. There's not a lot of space in that bony orbit to accommodate accumulating blood, so if a retrobulbar. hematoma is present, the patient is *at risk* for developing a compartment syndrome of the eye. You're correct that sometimes these can decompress on their own depending on how intact the bony orbit is. The safest option is to attempt lateral canthotomy if you have any clinical suspicion of compartment syndrome (the eye is rock hard when you touch it, elevated pressure, decreased vision, etc). The procedure is relatively easy and carries little morbidity. This procedure should be done without delay. Ophthalmology can be consulted afterwards. However, if I have a patient with normal eye pressures and Ophthalmology is involved and chooses not to do the lateral canthotomy, I would probably defer to them. Hope this helps!
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Ian L. - April 11, 2023 11:07 PM
There is enthusiasm developing to diagnose blood behind the orbit by point of care ultrasound .What about sedation IM say :
1-2mg midazolam ?
Jessie W. - April 12, 2023 11:09 AM
I usually just use lidocaine for pain control, but if your patient is really anxious a little sedation is always nice!
ST - April 28, 2023 10:59 PM
Please consider updating the video for how to perform a lateral canthotomy and cantholysis. The technique shown is incorrect/incomplete, and people following it will likely not get an adequate decrease in IOP. You have to pull the lower lid anteriorly to put tension on the inferior tendon to feel the "strum," and the tendon is not that far down into the orbit. When done correctly, the lower lid should easily flop down/out, which is not shown in the final photo at the end of the video.
There are videos of the procedure available on YouTube done by ophtalmology/oculoplastics that better show how to do the cantholysis and how distractible the lower lid should be when it's done:
https://www.youtube.com/watch?v=IV8JjyQ3cJQ
https://www.youtube.com/watch?v=kcB50sVOBKs
Jess Mason - May 2, 2023 9:50 AM
Thanks for sharing your tips. Those are good videos for reference as well. Ultimately what matters is the repeat IOP. If it went down then the end goal was achieved, and that is stated in the video. If I get footage clarifying this specific technique I can add it to the video. Thanks again.
jeff g. - May 1, 2023 7:16 AM
The language seems to imply that if a retrobulbar hematoma is present then there is by definition a compartment syndrome. However, as optho has informed me in the past, if lateral canthotomy fails the next step they take is breaking the bones of the compartment. Since many of these patient present with those bones are already blown out, the compartment pressures may not become elevated. I have seen patients with a hematoma that have had normal eye pressures and optho has chosen to follow without the lateral canthotomy being done.
Curious if this sounds reasonable to you or are they just taking an unnecessary risk not doing it, or having me do it?
Jessie W. - May 2, 2023 9:07 AM
Thank you for your question!
You bring up an important point: Bleeding behind the eye doesn't *always* lead to a compartment syndrome, but that is the feared complication. There's not a lot of space in that bony orbit to accommodate accumulating blood, so if a retrobulbar. hematoma is present, the patient is *at risk* for developing a compartment syndrome of the eye. You're correct that sometimes these can decompress on their own depending on how intact the bony orbit is. The safest option is to attempt lateral canthotomy if you have any clinical suspicion of compartment syndrome (the eye is rock hard when you touch it, elevated pressure, decreased vision, etc). The procedure is relatively easy and carries little morbidity. This procedure should be done without delay. Ophthalmology can be consulted afterwards. However, if I have a patient with normal eye pressures and Ophthalmology is involved and chooses not to do the lateral canthotomy, I would probably defer to them. Hope this helps!