Lateral Canthotomy/Cantholysis Performance Gap Analysis and Training Recommendations for Expeditionary Physicians

Preservation of life, preservation of limb, and preservation of eyesight are the priorities for military medical personnel when attending to casualties. The incidences of eye injuries in modern warfare have increased significantly, despite personal eye equipment for service members. Serious eye injuries are often overlooked or discovered in a delayed fashion because they accompany other life- and limb-threatening injuries, which are assigned a higher priority. Prehospital military ocular trauma care is to shield the eye and evacuate the casualty to definitive ophthalmic care as soon as possible, with exceptions for treatment of ocular chemical injury and orbital compartment syndrome. Retrospective analysis of eye injuries in recent conflicts identified gaps in clinical capabilities with up to 96% of ocular injuries being suboptimally managed. Ocular compartment syndrome (OCS) is a complication associated with orbital hemorrhage, where significant morbidity occurs as a result of increasing intracompartment pressure. The ischemic tolerance of the retina and optic nerve is approximately 90 minutes, so OCS must be rapidly diagnosed and aggressively treated through lateral canthotomy/cantholysis (LC/C) to prevent permanent vision loss. LC/C procedures consist of using hemostats to crush the lateral canthal fold and cutting the lateral canthal tendon from the inferior crus to relieve increasing intracompartment pressure. The purpose of this study was to examine the baseline capabilities of military physicians and surgeons to accurately and independently perform the LC/C procedures and identify performance gaps that could be closed through focused professional development activities. This study received institutional review board approval at our institution. A total of 60 subjects voluntarily participated in the study from emergency medicine (15), general surgery (28), and ophthalmology (17). All procedural assessments were performed 1:1 by expert faculty ocular trauma specialists using a high-reliability eye trauma simulator (Sonalysts, Inc.). The competency standard was set at independent and accurate completion of all procedural components and all critical procedural components. Analyses were performed using descriptive statistics and analysis of variance to examine between-group differences (P