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    3 Procedures for Eye-mergencies

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    When on call, response time can be critical to saving sight. Here are three procedures that, under the right circum­stances, can help you respond quickly. The first two address high intraocular pressure (IOP), the third eyelid trauma.

    1. Lateral Canthotomy and Cantholysis

    In the case of high IOP after orbital trauma, this can be an eye-saving procedure. Here’s how to do it:

    1. If time allows and the patient is conscious, use lido­caine for local anesthesia. A 25-gauge needle on a 3-cc syringe should suffice.
      Note: Especially if anesthesia is not delivered, it may be helpful to use a straight hemostat in the lateral fornix (one end on the skin and one on the conjunctival side of the eyelid). This can help with hemostasis.
    2. Use a straight Stevens scissor or other similar type to incise the eyelid. This is the canthotomy!
    3. Next, sever the canthal tendon. This is by far the most important step! With the lateral lid distracted from the face, place the scissors perpendicular and posterior to the lid (parallel with the cheek sur­face). Between the tynes, strum for the inferior crus of the tendon.
    4. Cut! You may have to make more than one cut. If you control the lateral edge of the lid, you will feel the edge of the eyelid come loose.
    5. If needed, apply pressure for three minutes for hemostasis. Make sure you check the IOP to con­firm your handiwork.

    2. Anterior Chamber Tap

    When heightened IOP results from an intraocular pro­cess, you can instead use a tap.

    1. Make sure the patient is comfortable and not going to accidentally move. Without a slit lamp, lie them supine on a firm bed. Do NOT use a pillow.
    2. Numb the ocular surface and consider placing a lid speculum if you have one handy.
    3. Place a 30-gauge needle on an open 1-cc syringe. This acts as a handle for your needle. Position your hand with the wrist supported and the needle bevel up. Use your non-procedural hand to hold the head steady and the eyelids open if a specu­lum is not available.
    4. Slide the needle into the cornea slow and steady, just anterior to the lateral limbus. Once you enter the anterior chamber, you will lose resistance against the needle.
    5. Withdraw the needle. You may see aqueous humor in the needle hub.
    6. Consider a betadine drop. Make sure to confirm the reduced IOP!

    3. Marginal Eyelid Laceration Repair

    Eyelid trauma can be delicate to examine and repair. Remember to rule out canalicular involvement, absence of foreign body, globe rupture and violation of the septum (entry into the orbit). Any of these may necessitate the use of imaging, either by B scan, CT or otherwise. Now to the eyelid margin:

    1. Flip the eyelid and examine defects for the above reasons and to examine the extent of tarsal plate damage. As a rule, you need to repair each rupture of the tarsus with partial-thickness sutures that do not extend posteriorly to the conjunctival side of the eyelid. A spatulated needle is preferable.
    2. Suture the wound:

    If treating children and patients with developmental limitations, consider a vertical mattress, but note that this is not a beginner’s technique:

    1. Use a 7-0 vicryl suture and pass from inside the wound, through the tarsus, to the lid margin.
    2. Start a new bite further from the wound back into the wound passing through the tarsus again.
    3. Do this in reverse on the opposing side of the wound (far throw to a short throw, back into the wound via the tarsus).
    4. Tie a 2-1-1 knot in the wound. This creates a verti­cal mattress (good wound eversion) with a knot in the wound that you do not need to remove in the future.
    5. Close the skin with absorbable interrupted sutures.

    For an easier technique:

    1. Start with placing a 6-0 interrupted silk suture through the lash line and another through the gray line. Do not tie them yet; one throw can help you maintain the lid orientation.
    2. Next, place a 5-0 vicryl spatulated needle partial thickness through the tarsus, away from the margin.
    3. Tie this in a 2-1-1 knot. The upper lid may require an additional tarsal throw, but typically the lower lid does not.
    4. Now, close the skin with interrupted throws. Smaller wounds can be closed with one or two sutures.
    5. Once you’ve tied the marginal throws, tie the skin sutures over them to hold them away from the ocular surface until you remove them.

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    James G. Chelnis, MDAbout the author: James G. Chelnis, MD, is assistant professor in oculoplastics at the New York Eye and Ear Infirmary of Mount Sinai. He is also chair of the Academy’s YO Info editorial board.