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.


[DDET Here is her CT-Brain…]

Retroorbital haematoma
Left sided proptosis with retroorbital haematoma


[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 !!!


[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.


  • Proptosis
  • Reduced visual acuity
  • RAPD
  • Markedly elevated intraocular pressure
  • Other consequences of trauma [subconjunctival haemorrhage, ecchymoses, facial fractures]


  • 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
  • Rapid saline clean to local skin.
  • Anaesthetise the lateral canthus with 1% lignocaine (+ adrenaline)
    • Consider parental analgesia ± procedural sedation.
  • THE CANTHOTOMY (images below).
    1. Before incising → crush the lateral canthus with small haemostat for 1-2 minutes [minimise bleeding]
    2. Incise the canthus with scissors.
      • Caution – avoid the eye.
      • Begin at lateral canthus & extend laterally to orbital rim ~ 1-2cm
    3. Continue by retracting the lower lid to expose the inferior crus of the lateral canthus.
LATERAL CANTHOTOMY – courtesy of The Trauma Professionals Blog
    • 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.
Courtesy of oculist.net.
CANTHOLYSIS – courtesy of oculist.net
  • Haemorrhage, infection & mechanical eye injury are possible [mainly globe rupture]
  • Urgent Ophthalmology consultation will be sought regardless.


[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.


[DDET References]

  1. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Portland, Ore: WB Saunders Co; 2009:Chap 63 1174-1177.
  2. Hill C et al. Prehospital lateral canthotomy. Emerg Med J. 2013 Feb;30(2):155-6.
  3. 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.
  4. Engeln, A et al. Under Pressure via Emergency Physicians Monthly. – Brilliant demonstration of a step-by-step canthotomy !!



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