eye for an eye…
the case.
an elderly female arrives to your ED with facial swelling and extensive bruising after a fall where she struck the left-side of her face on a concrete step. She is on warfarin for atrial fibrillation, but has not had her INR tested for the past 3 weeks.
She is GCS 15 with full power and tone in all 4 limbs. Her left eye is swollen shut.
[DDET Outline your principles of management…]
- Primary & secondary survey.
- ?concomitant injuries from fall
- Empiric reversal of coagulopathy.
- Low risk [indication of AF only]
- Options:
- Vitamin K
- Fresh frozen plasma
- Prothrombin complex concentrates
- Ideally: 35-50IU/kg PCC + 5-10mg IV vitamin K.
- Urgent cerebral and facial-bone CT
- Ophthalmic assessment.
- Needs rapid determination of left eye visual acuity.
- Also assess extra-ocular movements ?muscle entrapment.
- Assess for potential medical causes for fall.
- Analgesia.
- Antibiotic prophylaxis + tetanus booster.
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[DDET Here is her CT-Brain…]
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[DDET The case continues…]
- There are no other apparent injuries from her fall.
- Her INR returns at 5.4 !!
- She has already received 3000 units of Prothrombinex – phew !!
- Right pupil: 3mm reactive. Left pupil: 6mm & non-reactive to light.
- Visual acuity:
- Initially: able to count fingers at bedside.
- 5 minutes later: light perception only.
- 10 minutes later: nothing !!!
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[DDET What intervention can you perform in the ED that may alter her outcome ?]
Lateral Canthotomy.
Retroorbital haemorrhage/haematoma can create enough pressure to compromise the ophthalmic artery, resulting in orbital compartment syndrome. The optic nerve & its vascular supply, plus the central retinal artery are compressed – resulting in ischaemia & vision loss.
Goal of procedure: to release pressure on the globe & to decrease intraocular pressure enough to reinstitute retinal artery blood flow.
RELAVENT ANATOMY.
CLINICAL SIGNS:
- Proptosis
- Reduced visual acuity
- RAPD
- Markedly elevated intraocular pressure
- Other consequences of trauma [subconjunctival haemorrhage, ecchymoses, facial fractures]
INDICATIONS.
- Primary:
- Decreased visual acuity
- Intraocular pressure > 40mmHg
- Proptosis
- Secondary:
- Afferent pupillary defect
- Cherry red macular [ie. retinal artery compromise]
- Ophthalmoplegia
- Nerve head pallor
- Eye pain
TECHNIQUE.
- Rapid saline clean to local skin.
- Anaesthetise the lateral canthus with 1% lignocaine (+ adrenaline)
- Consider parental analgesia ± procedural sedation.
- THE CANTHOTOMY (images below).
- Before incising → crush the lateral canthus with small haemostat for 1-2 minutes [minimise bleeding]
- Incise the canthus with scissors.
- Caution – avoid the eye.
- Begin at lateral canthus & extend laterally to orbital rim ~ 1-2cm
- Continue by retracting the lower lid to expose the inferior crus of the lateral canthus.
- THE CANTHOLYSIS
- Incise the inferior crus of the lateral canthus.
- If symptoms [or IOP] has not improved → incise the superior crus.
- Alternatively; some clinicians advocate releasing both to begin with.
COMPLICATIONS.
- Haemorrhage, infection & mechanical eye injury are possible [mainly globe rupture]
- Urgent Ophthalmology consultation will be sought regardless.
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[DDET Case outcome…]
- A lateral canthotomy & cantholysis is performed in the resuscitation bay under procedural sedation.
- There is no significant improvement shortly after the procedure.
- Decision made with both Ophthalmology & Plastic Surgery to proceed to theatre for haematoma evacuation.
- Unfortunately; despite the above interventions her vision in the left eye did not return.
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[DDET References]
- Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Portland, Ore: WB Saunders Co; 2009:Chap 63 1174-1177.
- Hill C et al. Prehospital lateral canthotomy. Emerg Med J. 2013 Feb;30(2):155-6.
- Goodall KL et al. Lateral canthotomy and inferior cantholysis: an effective method of urgent orbital decompression for sight threatening acute retrobulbar haemorrhage. Injury. 1999 Sep;30(7):485-90.
- Engeln, A et al. Under Pressure via Emergency Physicians Monthly. – Brilliant demonstration of a step-by-step canthotomy !!
SOCIAL MEDIA.
- Life in the Fast Lane – Bashed, Blind and Bulging
- Resus.ME – Life, limb and sight-saving procedures.
- Broome Docs – Podcast 007 Eye Trauma.
- The Trauma Professionals Blog –
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