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[Link]
ORIGINAL INVESTIGATION
A human cadaveric model for effective instruction of lateral canthotomy and
cantholysis
Sheel R. Patel a
, Priti Mishallb,c, and Anne Barmettlerc
a
Albert Einstein College of Medicine, Bronx, NY, USA; bDepartment of Anatomy and Structural Biology, Albert Einstein College of Medicine,
Bronx, NY, USA; cDepartment of Ophthalmology and Visual Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx,
NY, USA
ABSTRACT ARTICLE HISTORY
Purpose: To evaluate a human cadaveric model in improving knowledge and comfort of Received 5 February 2019
ophthalmology residents performing a lateral canthotomy/cantholysis. Accepted 23 March 2019
Methods: A prospective study was conducted in ophthalmology residents, who participated in KEYWORDS
a workshop including an interactive lecture followed by hands-on training on a human cadaver. The Cadaver; cantholysis; lateral
lecture consisted of the indications and techniques of lateral canthotomy/cantholysis, along with video- canthotomy; ophthalmology
demonstration of proper technique. Residents practiced the procedure on cadavers under faculty workshop; resident training
supervision. Knowledge and comfort level of conducting the procedure was assessed pre- and post-
workshop.
Results: Post-workshop, the residents showed a significant improvement in general knowledge
regarding the technique of the procedure. Pre-workshop, the average knowledge score was 9
points out of 18 and this improved post-workshop to 12 points out of 18 (p < 0.0001).
Residents showed a significant improvement in comfort levels performing the procedure.
Using a Likert scale, the average comfort level of performing the procedure rose from 2.5
(Fair) prior to the workshop to 4 (Very Good) post-workshop (p = <0.01). All participants
reported an average score of 4.91 (1 = Strongly Disagree, 5 = Strongly Agree) that the human
model workshop was clinically applicable to their training and would impact the quality and
safety of patient care.
Conclusion: The study demonstrated an increase in knowledge and comfort in performing lateral
canthotomy and cantholysis using a cadaver model. With the time-sensitive nature of orbital
compartment syndrome, it is imperative that physicians are comfortable in performing this
procedure to prevent permanent vision loss.
Introduction and inconsistent. This results in residents who are
uncomfortable and/or incompetent in performing the
Orbital compartment syndrome is a vision-threatening
procedure. Evidence has shown that physicians who lack
emergency, where orbital compartment pressure
confidence and comfort in performing a procedure are far
increases due to mass effect. Once the compartment pres-
less likely to initiate and complete these medical
sure rises to the point where it exceeds perfusion pressure
procedures.2 The rarity of lateral canthotomy/cantholysis
of the ophthalmic artery, this results in ischemia and
procedures in patients translates to inadequate physician
irreversible vision loss if not treated emergently.1 Early
training and poorer outcomes for patients. In order to
intervention in the form of a surgical procedure, called
improve physician training and achieve better patient
lateral canthotomy and cantholysis, is necessary to pre-
outcomes, physicians need an alternative method for
vent permanent vision loss in patients with orbital com-
training – outside of the hospital setting.
partment syndrome. The vision-saving procedure is
While simulations, such as table tennis balls with rubber
frequently performed by ophthalmology residents,
bands and porcine models have been used, the purpose of
although the entity is also encountered by physicians in
the current study was to evaluate the use of a human
emergency medicine, internal medicine, otolaryngology,
cadaver to improve the knowledge and comfort of ophthal-
neurosurgery, plastic surgery, and in the burn unit.
mology residents in performing lateral canthotomy and
Unfortunately, the infrequent and emergent nature of
cantholysis.
this situation makes training of residents unpredictable
CONTACT Sheel R. Patel sheelpatel12@[Link] Albert Einstein College of Medicine, Bronx, NY, USA.
Supplemental materials data can be accessed here
© 2019 Taylor & Francis Group, LLC
2 S. R. PATEL ET AL.
Methods between pre- and post-workshop resident responses was
analyzed by Wilcoxon Signed-Rank test. Wilcoxon
This Institutional Review Board-approved, prospective
Signed-Rank test was used as the data collected with
study was adherent to the tenets of the Declaration of
Likert-scale items, and the scores from the questions
Helsinki. The objective of the study was to determine
assessing resident knowledge were non-parametric.
the effectiveness of a cadaver workshop in improving
Statistical significance was declared as a two-sided
the knowledge and increasing the comfort of the resi-
p-value <0.05. For descriptive statistics, mean and median
dents to perform the procedure.
values were calculated along with the interquartile ranges,
using the 25th and 75th percentiles as references.
Study design
Ophthalmology residents in their 2nd, 3rd, or 4th year of Results
post-graduate training participated in the workshop. At
Respondent attitudes
the beginning of the workshop, an oculoplastic surgeon
presented a 30-min lecture on indications and techniques Twelve of 12 ophthalmology residents completed the
of canthotomy and cantholysis, as well as a 2-min video workshop and questionnaires. Residents who participated
demonstrating the steps of lateral canthotomy and in the workshop demonstrated a statistically significant
cantholysis.3 At the end of the lecture, the oculoplastic increase in comfort with performing the canthotomy and
surgeon performed the surgical procedure on one side of cantholysis procedure; the average comfort level was 2.5
a cadaver to demonstrate the proper technique and illus- (Fair/Good) before the workshop and rose to 4 (Very
trate pertinent anatomic landmarks. Residents then split Good) after the workshop (p = 0.007) (Figure 1).
into small groups to each practice lateral canthotomy/ Not only did workshop participants feel more com-
cantholysis on cadavers. The oculoplastic surgeon pro- fortable performing a lateral canthotomy/cantholysis,
vided verbal feedback to each resident. but individuals also reported that their technical skills
Residents anonymously filled out the questionnaire improved with an average score of 4.83 and median
both before and after the workshop. The questionnaires score of 5 (Table 1).
assessed knowledge regarding the proper technique, indi- Attitudes towards the workshop itself were signifi-
cations, and tools needed for a lateral canthotomy and cant for 100% of respondents rating the workshop as an
cantholysis, along with questions assessing comfort with “Excellent” or “Very Good” training session in per-
performing the procedure on their own (see forming a lateral canthotomy and cantholysis (5-point
Supplemental Information). The questions assessing Likert scale). Additionally, all respondents (100%) felt
respondent knowledge were free response; this was cho-
sen over answer choices in order to simulate real-life
scenarios, where answer choices are not available.
Questions assessing comfort utilized the 5-point Likert
Scale: 1. Poor, 2. Fair, 3. Good, 4. Very Good, 5. Excellent.
For questions assessing knowledge of the indications,
technique, tools needed, and confirming a successful pro-
cedure, questionnaires were scored based on the number
of correct answers each respondent submitted, with the
highest possible score being 18 points. Finally, qualitative
data regarding opinions on the workshop and its effect
on the respondents’ perceived abilities to take care of
patients was collected from each respondent in the post-
workshop questionnaire, utilizing the 5-point Likert
scale: 1. Strongly Disagree, 2. Disagree, 3. Not Sure, 4.
Agree, 5. Strongly Agree. Figure 1. Improvement in pre-workshop and post-workshop
responses to the question “Using the following scale, what is
your comfort with performing a lateral canthotomy and cantho-
Statistical analysis lysis on your own?”; Likert scale used: 1 = poor; 2 = fair; 3 =
good; 4 = very good; 5 = excellent; ** indicates statistical
Analysis was carried out using IBM SPSS Statistics (IBM significance, P < 0.01 for Wilcoxon-Signed Rank test; The line
Corp. Released 2016. IBM SPSS Statistics for Mac, represents the median score in each group, with whiskers
Version 24.0. Armonk, NY: IBM Corp). Comparison representing the minimum and maximum values.
ORBIT 3
Table 1. Post-workshop scores demonstrated positive attitudes of residents towards using human cadaver model as an instructional
tool to practice lateral canthotomy and cantholysis.
Post-workshop score [mean; median and interquartile
Question range (25th and 75th percentile)]
1: Please rate the overall quality of the hands-on training session on lateral canthotomy/ 4.83; 5 (IQR 5–5)
cantholysis procedure using the cadaver model:
2: The experience was realistic enough to engage in learning. 4.58; 5 (IQR 4–5)
3: The exercise will be clinically applicable to my training or practice. 4.91; 5 (IQR 5–5)
4: This experience will impact the quality and safety of patient care. 5; 5 (IQR 5–5)
5: The feedback session with the faculty preceptor was facilitated effectively to encourage an 5; 5 (IQR 5–5)
open and honest dialogue.
6: The exercise served to enhance my TEAMWORK OR COMMUNICATION skills 4.66; 5 (IQR 4–5)
7: The exercise served to enhance my TECHNICAL OR PROCEDURAL skills. 4.83; 5 (IQR 5–5)
8: The exercise served to enhance my JUDGEMENT, CRITICAL-THINKING, OR DECISION- 4.66; 5 (IQR 4–5)
MAKING skills
9: The exercise helped me to better understand and/or apply institutional protocols, expert 4.5; 5 (IQR 4–5)
recommendations, or best-practice guidelines.
that the training workshop was clinically applicable and (p = 0.001). Knowledge on technique also improved. This
would improve the quality and safety of patient care. included two questions: one, on the orientation of scissors
Respondents agreed that the experience of using when performing the inferior cantholysis and one on
human cadavers was realistic enough to engage in assessment of procedure success (p = 0.007 and p =
learning with an average score of 4.58 and median 0.002, respectively). There was a trend to increasing under-
score of 5 (Table 1). standing of the indications of a lateral canthotomy and
Free response feedback on the workshop was very cantholysis, but this did not reach statistical significance
positive and encouraging. One respondent commented (p = 0.157) (Table 2). The lack of significant change
that the hands-on aspect of the workshop was necessary reflected the high pre-existing level of resident knowledge
to successfully learn how to perform a lateral canthot- of procedure indications on pre-workshop correct answers,
omy and cantholysis. Multiple respondents commented leaving very little room for improvement. The total num-
on the usefulness and necessity of such a workshop, ber of correct answers for all questions, an overall indicator
specifically in relation to the urgent nature of the pro- of resident knowledge, was aggregated for each respondent
cedure. Other respondents confirmed the effect of this and compared pre-workshop and directly post-workshop
workshop on increasing comfort levels in performing (Figure 2). There was a statistically significant improve-
the procedure, noting that they now would feel com- ment in the total number of correct answers for all parti-
fortable performing it on their own. cipants, going from a pre-workshop score of nine of
possible 18 points to a post-workshop total of 12 points
of the possible 18 (p < 0.001).
Respondent knowledge
The 12 ophthalmology residents who participated in the
Discussion
workshop showed statistically significant improvements in
knowledge. When asked to list the instruments and tools Orbital compartment syndrome typically results from
needed to successfully perform a lateral canthotomy and retrobulbar hemorrhage (RBH) due to orbital or facial
cantholysis, respondents were statistically significantly trauma. However, other causes also include local injec-
more accurate after completion of the workshop tions, orbital cellulitis, fluid resuscitation (especially after
Table 2. Percentage change in correct responses for individual questions on the knowledge questionnaire before and after the
lateral canthotomy and cantholysis workshop, along with associated P-values.
% Change in correct responses pre and
Questionnaire Item post-workshop P-Value
Q1: What are indications for a lateral canthotomy and cantholysis? 9.09% 0.157
Q2: Not including the supplies for local anesthesia, list the instruments and supplies needed for a lateral 28.53% 0.001
canthotomy and cantholysis procedure.
Q3: After canthotomy is performed, a cantholysis is required. During the cantholysis, what tissue should 0% 1
the forceps hold?
Q4: During cantholysis, at what structure should your scissors tips be pointed towards? 100% 0.007
Q5: After successful cantholysis, what exam findings will confirm the effectiveness of the procedure? 69.23% 0.002
P < 0.05 indicates statistical significance for Wilcoxon-Signed Rank test.
4 S. R. PATEL ET AL.
a higher level of comfort performing the procedure after
the workshop, but did not evaluate knowledge of indica-
tions or technique.5 However, differences between swine
and human eyelid anatomy such as eyelid position and
skin thickness make the simulation less realistic. One
attempt was reported, using a low-cost eye model by
Kong et al. This simulation utilized rubber bands,
a table tennis ball, and tape. Although much less life-
like, this was significantly cheaper; for $160 USD, 64
practice attempts were created vs. a simulation model,
such as the SynDaver Labs Lateral Canthotomy Trainer
(SynDaver Labs, Tampa, FL), where $750 USD only
allows for two practice attempts. While cost-
effectiveness was established in the Kong study, confi-
dence and knowledge improvements of the users was
not assessed.7
For more anatomically representative training,
Figure 2. Improvement in knowledge-based questions on lat- a human model is therefore preferred. Post-workshop
eral canthotomy; Comparing mean scores before and after the assessment showed that residents noted that the simu-
didactic workshop. Data are presented as the mean ± SEM; *** lation using human cadaveric models allowed better
indicates statistical significance, P < 0.001 for Wilcoxon-Signed visualization and mental preparation of the procedure.
Rank test. This is consistent with previous studies, which have
shown that when asked to compare learning modalities
for surgical training, human cadaver sessions were
burn injuries), orbital emphysema, foreign bodies, orbital ranked first over methods like textbooks, simulators,
mass, or abscess.4 The incidence of orbital compartment animal cadavers, and lectures. Human cadaver sessions
syndrome is low with the reported incidence of RBH have been shown to be more effective for learning
secondary to trauma being 0.45–0.6%, although the over- surgical anatomy, increasing confidence in performing
all incidence of orbital compartment syndrome has not a procedure, and for learning the steps of an
been established.1 Though rare, RBH causing orbital com- operation.8,9
partment syndrome can have dire consequences. In A human cadaver model has been reported for emer-
trauma patients, RBH is a serious event with up to gency medicine attending physicians, who ranged in
44–52% of patients becoming permanently blind (defined experience from immediately post-fellowship to 20 years
as visual acuity of less than 20/400 or a visual field loss to of specialist practice. This study evaluated a number of
less than 10 degrees).1 emergency medicine procedures, including lateral
With the low incidence of orbital compartment syn- canthotomy/cantholysis, and showed a statistically signif-
drome, clinical experience is inadequate in preparing icant improvement in understanding the indications for
physicians to perform the required time-sensitive, the canthotomy/cantholysis and comfort with performing
vision-saving procedure competently. A human cadaver the procedure.6 However, proper technique was not eval-
workshop most similarly recreates the desired scenario uated. While knowledge of procedure indications and
and is effective in teaching ophthalmology residents comfort with the procedure are important, the ability to
how to perform a vision-saving lateral canthotomy perform the procedure correctly is vital to vision preser-
and cantholysis procedure, while also improving their vation. Another limitation to the study is that only emer-
comfort levels in performing this procedure. gency medicine attendings were included; no other
Studies examining effectiveness of hands-on work- specialties and no residents participated. While it is
shops in training students, residents, and/or attending important for emergency medicine attendings to be able
physicians to perform a lateral canthotomy and cantho- to perform a lateral canthotomy and cantholysis, many
lysis are sparse; there are three in the English literature.5–7 other specialties and residents will also encounter orbital
One study utilized a porcine model to teach emergency compartment syndrome and need to be able to recognize
medicine residents and fellows proper technique for and manage it efficiently and efficaciously. With ophthal-
a lateral canthotomy/cantholysis, via a hands-on mology residents being one of the most frequently con-
session.5 Results showed that residents and fellows had sulted to the Emergency Department and throughout the
ORBIT 5
hospital to perform lateral canthotomy and cantholysis, it improvement in the participant’s ability to perform
is important for them to be comfortable performing this a lateral canthotomy and cantholysis. This could be
procedure. This Institutional Review Board-approved, addressed by directly monitoring the residents’ per-
prospective study is the first of its kind to evaluate the formance of a lateral canthotomy/cantholysis before
improvement in knowledge and comfort of the individual and after the workshop. Since there is evidence that
performing the procedure, specifically for ophthalmology resident training via video-recorded assessment and
residents. feedback from faculty improves technical skill and
Knowledge and comfort have long been established quality of surgical procedures, future studies could
reasons for cadaver-based teaching, which have been utilize a video recording of residents performing the
shown to be effective in improving resident confidence procedure before and after the workshop.10 Due to
and fundamental operative techniques.10 Cadaver- the questionnaires being administered before and
based surgical simulation for residents, in the presence shortly after the conclusion of the workshop, long-
of faculty members, has been shown to not only term knowledge and comfort were not assessed.
increase the confidence levels of the trainee in perform- Future studies could assess long-term retention with
ing the procedure, but also the confidence levels of the an additional post-workshop questionnaire six
attending physician in the trainee to perform proce- months to a year afterwards. Assessment of comfort
dures autonomously.10 In this case, teaching procedural levels in performing an in vivo canthotomy and
skills during cadaver dissections, such as the one cantholysis pre- and post- workshop could also be
demonstrated in this study, results in increased resident included.
comfort and knowledge that cannot be achieved in the A human cadaver workshop was able to increase the
clinical setting alone due to the low incidence of orbital confidence and comfort levels of ophthalmology resi-
compartment syndrome. dents in performing a lateral canthotomy and cantho-
With increased confidence and comfort from both lysis. This method of teaching was also rated favorably
the trainee and attending, residents are more likely to by participants as a means of improving their clinical
initiate and perform a medical procedure and this will skills and positively effecting patient care in the future.
lead to more experience and practice. Evidence shows Increasing awareness and use of similar workshops to
that physicians are far less likely to initiate and perform train residents will be crucial in performing this vision-
medical procedures, in which they lack confidence and saving procedure efficiently and effectively.
comfort.2 The present study confirms that a procedural
workshop for lateral canthotomy increases the confi-
dence and knowledge of participants. This workshop, Conclusion
therefore, has the potential for longer lasting effects
such as an increased likelihood to initiate the procedure A human cadaveric model for teaching lateral canthot-
in the appropriate situation, to perform the procedure omy and cantholysis was effective in increasing knowl-
correctly, and to do so in an autonomous fashion.2 edge and importantly, the comfort of resident
While a human cadaver lateral canthotomy work- physicians in Ophthalmology. With the time-sensitive
shop is an effective training and teaching tool for nature of managing orbital compartment syndrome, it
resident physicians, there are limitations in the cur- is imperative that physicians are competent and com-
rent study that could be addressed through future fortable in performing a lateral canthotomy and
research. Firstly, human cadaver models do not cantholysis to prevent permanent vision loss.
include confounding factors often encountered during
an emergent lateral canthotomy, such as proptosis
and bleeding. Future models could expand upon this Acknowledgments
study to include these factors and allow more objec- The authors wish to thank Dr. William Burton for his exper-
tive measures of a successful procedure such as mea- tise and guidance with statistical tools for the study. Most
suring intraocular pressure on the model eye. Human importantly, the authors acknowledge and gratefully thank
cadaver models are also more costly than other simu- the individuals whose bodies were used in this study for the
advancement of medical education and patient care.
lation models, which may decrease accessibility.
Secondly, due to a study design of asking respondents
to complete pre- and post-workshop questionnaires
rather than directly assessing the performance of the Disclosure statement
procedure, our data reports improved knowledge and The authors report no conflicts of interest. The authors alone
comfort, but cannot conclusively say there was an are responsible for the content and writing of the article.
6 S. R. PATEL ET AL.
Authors‘ contributions 2. Maibach EW, Schieber RA, Carroll MF. Self-efficacy in
pediatric resuscitation: implications for education and
PM and AB created the workshop curriculum. AB instructed performance. Pediatrics. 1996;97:94–99.
the residents through lecture-based and hands-on instruction 3. Rixen J, Verdick R, Allen RC, Carter KD,
during the workshop. SP administered the survey and ana- Canthotomy L, Cantholysis. [Video File]. 2013;
lyzed the data. All authors wrote and reviewed the final [Link]
manuscript. Accessed August 3, 2016.
4. Domino FJ, Baldor RA, Golding J, Stephens MB. The
5-Minute Clinical Consult 2017. 25th ed. Philadelphia:
Availability of data and material Wolters Kluwer; 2017.
The datasets used and/or analyzed during the current 5. Suner S, Simmons W, Savitt DL. A porcine model for
instruction of lateral canthotomy. Acad Emerg Med.
study are available from the corresponding author on 2000;7:837–838.
reasonable request. 6. Ferguson IM, Shareef MZ, Burns B, Reid C. A human
cadaveric workshop: one solution to competence in the
face of rarity. Emerg Med Australas. 2016;28
Ethics approval and consent to participate (6):752–754. doi:10.1111/1742-6723.12521.
This study was approved by the Institutional Review Board of 7. Kong R, Kaya DP, Cioe-Pena E, Greenstein J. A low
the Albert Einstein College of Medicine. Verbal consent was fidelity eye model for lateral canthotomy training. Afr
obtained from all medical residents participating in the work- J Emerg Med. 2018;8(3):118–122. doi:10.1016/j.
shop, as approved by our Institutional Review Board. afjem.2018.02.002.
8. Lewis CE, Peacock WJ, Tillou A, Hines OJ, Hiatt JR.
A novel cadaver-based educational program in general
ORCID surgery training. J Surg Educ. 2012;69(6):693–698.
doi:10.1016/[Link].2012.06.013.
Sheel R. Patel [Link] 9. Katz R, Hoznek A, Antiphon P, Van Velthoven R,
Delmas V, Abbou CC. Cadaveric versus porcine mod-
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