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Case 1.13
Published in Monica Fawzy, Plastic Surgery Vivas for the FRCS(Plast), 2023
I will call my Ophthalmology colleague for support but in the meantime, I will perform an emergency lateral canthotomy and cantholysis, which is a bedside release of the inferior crus of the lateral canthal ligament to decompress the orbital nerve.
Management of Ophthalmic Injuries by the Forward Surgical Team
Published in Mansoor Khan, David Nott, Fundamentals of Frontline Surgery, 2021
Richard J. Blanch, Johno Breeze, William G. Gensheimer
Orbital compartment syndrome should be managed as follows:Perform immediate lateral canthotomy and cantholysis (Figure 16.6).Evacuate urgently for ophthalmology assessment and possible secondary procedures (including medical management and orbital decompression).If performed competently, this is a low-morbidity procedure, and the lateral canthus heals well by secondary intent, with no need for surgical repair. When doubt exists as to whether an orbital compartment syndrome is present, it is, therefore, preferable to perform an unnecessary canthotomy/cantholysis than fail to perform a necessary one.Do NOT perform only a lateral canthotomy. This is an ineffective procedure.Assess the globe again, as this will be improved once the lateral canthotomy/cantholysis has been performed.
Management of orbital injury and expanding orbital haematoma
Published in S. Musheer Hussain, Paul White, Kim W Ah-See, Patrick Spielmann, Mary-Louise Montague, ENT Head & Neck Emergencies, 2018
Bridget Hemmant, Carl Philpott
Lateral canthotomy (Figures 5.8 and 5.9): A pair of sharp straight scissors are used to make a cut in the lateral canthal angle (canthotomy), and then the scissors are rotated 90° to cut through the lateral canthal tendon (lateral cantholysis) at its attachment to the bony orbital rim. The third cut is to cut deep to the skin, but through the orbital septum and conjunctiva below the tarsal plate in order to allow the haematoma to drain (Figure 5.9). In addition, the orbital pressure should be reduced. The patient should be given mannitol – 1 gm/kg IV over 30 minutes – plus acetazolamide – 500 mg IV. An urgent ophthalmology review should be arranged and an external (or endoscopic) orbital decompression considered as the next immediate intervention, depending upon effectiveness of the canthotomy. As visual loss is the main risk with a retrobulbar haemorrhage, reducing the pressure in the orbit and allowing the haematoma to evacuate are the main concerns. Cosmesis is a secondary issue, as eyelid reconstruction is possible at a later date if required. Table 5.1 summaries these steps.
Severe orbital inflammation and hemorrhage complicating bleomycin sclerotherapy for orbital lymphaticovenous malformation
Published in Orbit, 2023
Urgent admission was arranged, scrapings were taken from the right cornea for microscopy and culture, and she was commenced on hourly preservative-free levofloxacin eye drops, hourly preservative-free carbomer gel, soft-paraffin ointment three times daily, oral ciprofloxacin 500 mg twice daily and oral dexamethasone 4.5 mg daily (weight-adjusted dose). Due to the fact that five days had elapsed since the onset of her symptoms, the optic nerve was thought to be irretrievably damaged. Furthermore, she was not in pain. Therefore, no anti-osmotic or pressure lowering agents were prescribed, and lateral canthotomy/inferior cantholysis was not performed. CT imaging confirmed a 59 × 51 × 36 mm hematoma in the right posterior orbit surrounding the optic nerve and severe right proptosis (Figure 2D). Orbital decompression was considered but was deemed to be unnecessary, with the potential to cause further bleeding. The day after admission a multi-layer amniotic membrane graft was performed, combined with traction sutures to right upper and lower lids to close the palpebral aperture and protect the compromised ocular surface. The corneal scrape grew Coryne pseudodiptheriticum with scanty growth of Staphylococcus epidermidis, of uncertain clinical significance. Due to the severity of the keratitis and potentially low penetration of topical antibiotics in the presence of the amnionic membrane graft, oral flucloxacillin 500 mg four times daily was added to her antibiotic regime.
A rare case of intramuscular angioma involving the medial rectus muscle
Published in Orbit, 2022
Ricarda Bentham, David R. Jordan, James Farmer
A differential diagnosis included non-specific orbital inflammation of the medial rectus (yet no history of inflammation or pain), thyroid eye disease (although no history of a thyroid abnormality in the past, negative family history and blood work), or neoplasia (e.g., lymphoma, sarcoma, metastatic disease). The diagnostic possibilities were discussed with the patient and a biopsy of the growth was suggested. Under general anesthesia, a canthotomy, cantholysis and swinging eyelid approach were carried out to the orbital rim. Periorbita was opened along the rim and after careful dissection along the orbital floor (15–20 mm), the periorbita was opened and using malleable brain retractors to gently spread the tissue, a dark red mass was identified. The mass could not be delineated from the medial rectus muscle; the mass and the medial rectus appeared to be one in the same. At times, it appeared larger depending on how the malleable retractors were being held and with a slight adjustment of the retractors was smaller. The mass bled easily even with gentle tissue manipulation and cauterization was required with bipolar cautery. Westcott scissors and 0.5 mm Castroviejo toothed forceps were used to obtain 2 biopsies; bleeding was prominent, and cautery was again required several times to stop it.
Spontaneous retrobulbar hemorrhage in the setting of warfarin therapy and latent scurvy diagnosis
Published in Orbit, 2022
Brian W. Chou, Quinn N. Rivera, Courtney E. Francis
Retrobulbar hemorrhage is a vision-threatening emergency that most commonly occurs in the setting of facial trauma or surgical manipulation, presenting with sudden onset of pain, pressure, proptosis, and ophthalmoplegia. Rapid canthotomy and cantholysis to release the orbital compartment must be undertaken to prevent vision loss.1 Spontaneous nontraumatic hemorrhages are much rarer, and a thorough evaluation must be considered in patients. anti-coagulation alone, in the absence of supratherapeutic levels, is unlikely to cause a nontraumatic retrobulbar hemorrhage, and other contributing factors should be considered, including orbital vascular anomalies. Larger malformations may be easily identifiable on imaging, but smaller vessel weaknesses may be more difficult to identify.