Prophylactic lateral canthotomy and cantholysis allow graded reconstruction of eyelids with multifocal stellate lacerations

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• Case Report
• Discussion
• References
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Lateral canthotomy and cantholysis are well described in the following settings: (i) acute management of retrobulbar hemorrhage¹; and (ii) reconstruction of full-thickness eyelid defects.² I describe a patient who was involved in a motor vehicle accident and presented with multifocal stellate lacerations of upper and lower eyelids as well as a scleral rupture on the ipsilateral side. A controlled lateral canthotomy with disinsertion of the inferior and superior crus of the lateral canthal tendon allowed complete reconstruction of the eyelids in the same setting as the globe repair. A staged repair of the induced lateral canthal deformity resulted in functional eyelids as well as a good visual outcome.

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Case Report 

A 17-year-old female was involved in an accident in which her car hit a tree. She suffered a closed head injury and was intubated at the scene. The shattered windshield was associated with multifocal right upper and lower eyelid stellate lacerations involving the tarsal plate, lid margin, and lateral canthus (Fig. 1). She was transported to the Ohio State University emergency room and admitted to the intensive care unit. A CT scan did not reveal any intraocular or intraorbital foreign bodies.

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• Fig. 1. 

  Complex multifocal upper and lower eyelid lacerations with partial lateral canthal laceration and evidence of orbital penetration, with fat prolapsed.

There was mild orbital congestion but no relative afferent papillary defect. Under anesthesia, the anterior chamber and vitreous cavities were clear and the retina was attached. The intraocular pressures were 12 mm Hg bilaterally by Tonopen. In the superotemporal quadrant, a brown tissue was noted beneath the conjunctiva, raising suspicion for a small area of scleral rupture. This was explored under the operating microscope and repaired by 3 interrupted 8-0 Vicryl sutures.

As the upper tarsal plate was gradually pieced back together, it began to exert pressure on the freshly repaired globe. A lateral canthotomy was performed followed by disinsertion of the superior and inferior crus. This allowed extensive primary repair of her complex eyelid lacerations without exerting any undue pressure on the globe.

She developed a lateral canthal deformity (displaced inferolaterally) and cicatricial upper and lower eyelid retraction resulting from contracture of the anterior lamella. At 6 months after the initial repair, she underwent lateral canthoplasty and full-thickness supraclavicular skin grafts to the upper and lower eyelids. Now, 8 years after the initial trauma, she remains with 20/20 vision, no lagophthalmos, and a reasonable cosmetic result (Fig. 2).

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• Fig. 2. 

  Excellent symmetry of lid position and contour is noted 1 year after staged reconstruction of the lateral canthus and skin grafting to the anterior lamellae of the upper and lower eyelids.

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Discussion 

Lateral canthotomy and cantholysis are well described in the acute management of retrobulbar hemorrhage.¹ In this setting, they relieve the squeezing effect on the globe from the tight eyelids anteriorly and the space occupying hemorrhage posteriorly. Releasing the superior or inferior crus of the lateral canthal tendon is also well described in the oculoplastic reconstruction of full-thickness eyelid defects to increase horizontal mobility toward simple direct closure.²

The present case demonstrates the use of lateral canthotomy and cantholysis prophylactically in a congested orbit with a freshly repaired scleral rupture. This allowed extensive eyelid laceration repairs while avoiding a compartment syndrome in this delicate setting. Once the orbital congestion had resolved, and the globe and eyelids had healed, a staged lateral canthoplasty was combined with repair of the cicatricial retraction.

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References 

1. Ballard SR , Enzenauer RW , O'Donnell T , et al.  Emergency lateral canthotomy and cantholysis: A simple procedure to preserve vision from sight-threatening orbital hemorrhage . J Spec Oper Med . 2009;9:26–32
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2. Rodriguez-Sains RS , Jakobiec FA . Eyelid and conjunctival neoplasms . In:  Lisman RD ,  Levine MR editor. Smith's Ophthalmic Plastic and Reconstructive Surgery, 2nd ed . St. Louis: Mosby; 1998;p. 582
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