Numerous mechanisms of blunt and penetrating facial trauma may result in eyelid lacerations. Even seemingly innocuous blunt objects in the workplace can cause eyelid lacerations in experienced workers.[1]
View Image
Penetrating lid trauma with extensive periorbital ecchymosis. A ringlike projectile was ejected from a pipe fitting under high pressure. The patient a....
Eyelid lacerations may (1) involve the lid margin, requiring a meticulous suture technique; (2) be extramarginal; or (3) cause tissue loss.
View Image
Extramarginal upper lid laceration from blunt trauma in an infant. Such lacerations tend to follow relaxed skin tension lines.
Proper management includes the following:
Excluding any accompanying injury to the globe
Protecting the cornea and maintaining proper lid dynamics
Eyelid lacerations are most frequently encountered in young men, but can occur at any age and have even been described in newborns after cesarean delivery.[2]
Location
In a study from Iran, the right upper lid was the most frequently involved site of injury.[3]
The visual prognosis for lid lacerations is usually excellent unless there is accompanying globe rupture.
With proper reconstruction of lid lacerations, the cosmetic result is usually quite good. Lid notching, cutaneous scars, and cicatricial ectropion may require revision surgery.
The ophthalmologist usually is not called to the emergency room until life-threatening injuries are stabilized. The ophthalmologist should still take a thorough history and carefully review the notes of the other trauma physicians. Record standard information, such as the last oral intake, allergies, and tetanus status.
Ascertaining the mechanism of injury is important, as this may indicate associated injuries (eg, cervical trauma), the depth of the ocular adnexal injury, and possibly a foreign body.[1]
Windshield-related accidents may be associated with a foreign body and tissue loss.
Bite wounds may implicate infection (eg, rabies) and tissue loss. In human bite wounds, determine the assailant's HIV and hepatitis status.
In patients with small penetrating lid lacerations, maintain a high index of suspicion for underlying globe trauma.
Document prior visual function, the time of the injury, use of safety glasses, and accident witnesses.
In some cases, pertinent history may not be revealed to the clinician.
Patients who are inebriated or under the influence of recreational drugs may not be good historians. Confirmation with family members or acquaintances may be required.
Children might conceal the details of their injury for fear of parental rebuke or implicating a playmate who caused the injury. Be especially wary of underlying foreign bodies in children.
The patient's airway, breathing, circulation, and cervical spine should be cleared before addressing ocular adnexal trauma. Perform a quick gestalt of the patient, and review the vital signs. Precede lid repair with a thorough eye examination to exclude globe rupture.
If no globe rupture is present, evert the lids and flush the fornices, if needed. If the lids are markedly edematous, Desmarres retractors will aid in ocular examination. (If a Desmarres retractor is unavailable, a bent paper clip may be used.) Palpate and examine the lids for foreign bodies, including contact lenses.
Hyphema, orbital fractures, and other ocular adnexal trauma often occur with lid trauma.
Exclude injury to the levator, medial canthal tendon, lateral canthal tendon, canaliculi, and supraorbital nerve.
The presence of orbital fat indicates disruption of the septum and possible injury to the levator. In conscious patients, test levator function by splinting the brow and asking the patient to look up and down.
Displacement or rounding of the canthal angles suggests canthal ligament injury.
If the puncta are displaced or lacerations medial to the puncta are present, gently probe the canaliculi.
In patients with superonasal lacerations near the orbital rim, test for supraorbital anesthesia prior to anesthetic injection.
Diagram and measure lid lesions. Photograph the lid lesion, if appropriate. Patients may not realize the extent of their injury, and photography may aid in later compensation issues.
If occult foreign body is suspected, obtain neuroimaging studies.
The patient and family members should be given specific preoperative counseling regarding the possibilities for vision loss, lid malposition, cutaneous scarring, and possible need for further surgery. Patients should understand that some degree of scarring will result even with meticulous oculoplastic repair.
In patients with glass or windshield injuries, occult, embedded glass may chronically extrude. Inform patients of this possibility.
CT scan may confirm or reveal foreign bodies, a retrobulbar hemorrhage, a globe rupture, or an orbital fracture.
Depending on the size and lead content, glass foreign bodies may or may not be seen on radiography.
Orbital wood foreign bodies can be difficult to detect but may appear isodense with orbital fat. If no metallic foreign body is present and yet orbital wood is suspected but not seen on CT scan, an orbital MRI should be obtained.[4]
Infections, including periorbital necrotizing fasciitis[5] (streptococcal gangrene), occurring after upper eyelid lacerations have been described. Therefore, clinicians must maintain a high index of suspicion for any accompanying infections in patients with eyelid trauma.
Tetanus
If the patient has never been immunized, administer 250 U of intramuscular human tetanus immune globulin.
Administer intramuscular or subcutaneous tetanus toxoid (0.5 mL), if the patient did not have tetanus immunization in the preceding 10 years.
For unclean wounds or puncture wounds, administer tetanus toxoid for patients who have not had it within 5 years.
Animal bite wounds
Oral flora, such as Streptococcus, Pasteurella, and Bacteroides species, may infect bite wound lacerations. Capnocytophaga canimorsus (dysgonic fermenter type 2) infection is a potentially life-threatening virulent infection that can result after dog bites, especially in splenectomized patients.[6]
Wound debridement and copious irrigation (eg, bacitracin) is important for all bite wounds. Useful intravenous antibiotics include penicillin G, cefazolin, and ampicillin sulbactam. Antibiotic selection and dose should be confirmed with the hospital pharmacy and an infectious disease specialist.
In bite wounds that are older than 24 hours, consider allowing the wounds to granulate, if there is adequate corneal protection.
Rabies
If the bite was from a wild animal, administer rabies prophylaxis if brain tissue from the offending animal cannot be examined.
If a domestic pet was the culprit, check the rabies immunization status and quarantine the animal for 10 days, preferably with a veterinarian.
If a patient has a ruptured globe and a lid laceration, first repair the globe rupture. If there is an extensive lid laceration in this setting, lid speculums may not work. Traction sutures (eg, 4-0 silk) on the lacerated lid segments will facilitate globe repair.
Although repair of lid lacerations can be delayed, early repair may allow better corneal protection, less tissue edema, and better wound decontamination. If the lid repair must be delayed in favor of more life-threatening injuries, perform the following:
Ensure adequate corneal lubrication.
Clean the wound as much as possible.
Keep the wound moist. A plastic occlusive dressing, like that used to cover intravenous sites, can be lightly applied over antibiotic dressing to help protect the cornea.
Consider systemic antibiotic coverage.
Try to save or retrieve all lid tissue. The ocular adnexa has a good blood supply, and even ischemic-appearing tissue often heals.
Most adult lid lacerations can be repaired in the emergency department under local anesthesia. Good lighting and loupe magnification will aid wound exploration and repair.
Patients may be more comfortable in a slight reverse Trendelenburg position on a stretcher in the emergency department.
In uncooperative, inebriated patients, it may be better to delay the repair until the patient is sober.
Other uncooperative patients or children may require general anesthesia.
Administering topical anesthetic drops and topical lidocaine gel followed by placing a corneal protector, when possible, is one preferred method. The corneal protector can be inserted with sterile gloves prior to anesthetic injection. Injecting anesthetic with epinephrine prior to wound cleansing affords better patient cooperation and wound visualization.
Eyelid necrosis following lidocaine with epinephrine injection is rare but has been described. Epinephrine may cause prolonged vasoconstriction and is a relative contraindication in patients with sickle cell disease, arteritis, Raynaud phenomenon, and severe microvascular disease.[7]
Supplemental regional blocks may be helpful in pain control. For example, an infraorbital nerve block may be given to patients with lower lid lacerations.
After adequate anesthesia, the next objective is wound cleansing and decontamination.
Stevenson has described hydraulic irrigation with a 19-gauge needle on a 20-mL syringe.[8] The plastic hub of an intravenous catheter can be used in place of a needle.
Excessive tissue irrigation can cause lid edema. Wound irrigation with normal saline or bacitracin soak with a 10 mL-syringe sans needle or a bulb syringe is preferred.
After preparing and draping, carefully inspect wounds for foreign bodies.
If particulate matter is embedded in the wound, cleansing the skin with a surgical scrub brush will help prevent a traumatic tattoo.
Debriding the tissue with a chalazion curette is helpful. The curette can also be used to palpate for foreign bodies.
Orbicularis retraction may give the appearance that some of the lid tissue is missing when it actually is not.
Injuries that involve the medial canthus may involve the canaliculi. It is usually easiest to repair canalicular injuries prior to lid margin and canthal injuries. Instilling viscoelastic in the intact canaliculus may help in identification of the lacerated canaliculus. The medial cut end of the lower canaliculus may be more easily visualized if an upper punctal probe is pushed towards the lower lid lacerated skin margin.[9] Alternatively, a round-tipped, eyed pigtail probe, placed through the intact canaliculus, can help in the identification and repair of the lacerated canaliculus, if the patient has a common canaliculus.[10]
Monocanalicular stents (eg, Mini Monoka) are becoming increasingly popular. Bicanalicular stents, such as Crawford/Ritleng tubes, are commonly used and readily available.
Canalicular repair is best accomplished with the operating microscope. After the canalicular system has been intubated with a stent, 3 sutures can be placed around the canaliculus. Some advocate 10-0 nylon sutures for canalicular repair. Because they are easy to use and less prone to tearing, 8-0 polyglactin sutures also are preferred. If a bicanalicular stent is employed, tighten the bicanalicular stent prior to tying the sutures to decrease suture tension.
Medial canthal avulsions are usually surgically repaired. However the use of bicanalicular stenting alone, without posterior lacrimal crest fixation, has been described.[11] Lacerations of the deep head of the medial canthal ligament cause telecanthus (unlike lacerations of the superficial head of the canthal ligament). Medial canthal degloving injuries often present with a vertically oriented laceration traversing the medial canthus, with telecanthus, ptosis, and nasolacrimal injury. Repair should be performed in a staged fashion, first addressing telecanthus and lacrimal system. Ptosis surgery is usually done at a later stage.[12]
Posterior tendon repair should precede lacrimal repair, but bicanalicular intubation is easier to perform prior to definitive posterior tendon repair.
In some instances, the deep head of the tendon can be reattached to the posterior lacrimal crest or medial orbit with a microscrew or plating system. If not possible, transnasal wiring may be required.
Lid margin lacerations are usually repaired prior to extramarginal lacerations to allow for better anatomical realignment. The author prefers to use a single vertical mattress[13] stitch of 6-0 silk or 6-0 polyglactin to realign the lid margin. Traditionally, however, three marginal sutures of 6-0 caliber are used to realign the lid margin; this technique is described below.
The first suture passes through the plane of meibomian orifices with additional sutures placed anteriorly and posteriorly.
The suture ends are kept long and secured on the cutaneous antemarginal surface.
The lid margin sutures should slightly evert the lid margin to prevent lid notching. A vertical mattress suture may facilitate eversion of the lid margins.[13]
If the antemarginal tarsus is lacerated, two or three 6-0 polyglactin sutures can be placed through one-half to three-quarters thickness tarsus with the knot ends directed away from the cornea.
The orbicularis can be closed with 6-0 polyglactin suture.
Skin can be closed with 6-0 fast-absorbing gut suture or 6-0 nylon. The ends of the lid margin suture can be secured in 1 or preferably 2 cutaneous extramarginal sutures.
If it is suspected that the patient will not comply with follow-up care, use absorbable sutures for the entire lid repair.
In children who may not cooperate for later stitch removal, 6-0 fast-absorbing gut suture can be used if the laceration does not involve the lid margin. Keep in mind that if the child frequently rubs the eyes or sleeps prone, the fast-absorbing gut sutures may prematurely come loose.
Cutaneous sutures are removed on days 5-7, and Steri-Strips can be applied, if necessary. Removal of lid margin sutures at day 11-14 is a preferred method.
Extramarginal lid lacerations often follow relaxed skin tension lines; they heal well, if tissues are properly reapposed. As with all lid repairs, minimize vertical tension. In large upper lid extramarginal lacerations, using the eyebrow hairs as a landmark may allow better anatomical tissue realignment. If suturing dark eyebrow hairs, using a stitch that is not black aids in visualization.
Small lacerations that parallel the relaxed skin tension lines may sometimes be closed with Steri-Strips. Dermabond (2-octyl cyanoacrylate), a glue, has been described for skin closure; however, care must be taken to ensure that this glue does not adhere to the lids or touch the cornea. Glue should not be used for jagged, stellate, deep, contaminated, bite, or crush wounds.
In closing deep lacerations, avoid attaching the muscle, skin, or levator to the orbital septum; otherwise, lid lag occurs. Closure in layers and eversion of skin edges provides the best cosmesis.
Dehiscence of the lateral canthal ligament is not uncommon and may not be apparent when the lid is edematous and the patient is supine. Repair the lateral canthal ligament at the time of lid laceration, unless marked proptosis is present.
Posttraumatic upper lid ptosis
In patients with marked lid edema, judge the severity of posttraumatic ptosis after the edema has resolved.
When judging lid height, instill topical anesthetic in the eye to exclude the possibility of ocular irritation as a cause of lid closure. If the patient is also being dilated, remember that phenylephrine drops may alter the lid height.
One preferred method is to wait up to 6 months for spontaneous improvement of traumatic ptosis, unless there is the potential for amblyopia or the patient is monocular.
Postoperative care
Ensure adequate corneal lubrication, if required.
As with other eyelid surgeries, head elevation, cold compress, and antibiotic ointment are advisable.
Antibiotic ointments, including erythromycin or antibiotic steroid preparations, such as Maxitrol (neomycin, polymyxin, bacitracin, dexamethasone), used 3-4 times daily, are recommended.
Steroid ointment should be used with caution if underlying infection or corneal abrasion is suspected.
Patching is usually not preferred, so that visual acuity can be checked and undue pressure on the globe avoided. Apply a transparent eye shield if either of the following is suspected: the patient will rub the eyelids when awakening from the anesthetic, or the patient will rub the eyes when sleeping.
View Image
Preoperative. This child had a dog bite injury with a double lower lid margin laceration, dehiscence of the lateral canthal tendon, and disruption of ....
View Image
Postoperative. The inferior canaliculus was repaired with bicanalicular stenting. Lateral canthus reattachment and repair of lid margin lacerations wa....
Although pain management should be assessed on an individual basis, most patients do not require analgesia that is stronger than acetaminophen.
Occasionally, corneal ulceration may result from corneal exposure or an exposed suture that rubs against the cornea. Tell patients to return if they have persistent ocular discomfort or unexplained anterior segment erythema.
The eyelids have an excellent vascular supply. In the rare instance of postoperative wound necrosis, hyperbaric oxygen may be useful.[14]
Edsel Ing, MD, MPH, FRCSC, Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto Faculty of Medicine; Active Staff, Michael Garron Hospital (Toronto East Health Network); Consulting Staff, Hospital for Sick Children and Sunnybrook Hospital, Canada
Disclosure: Nothing to disclose.
Specialty Editors
Simon K Law, MD, PharmD, Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine
Disclosure: Nothing to disclose.
Chief Editor
Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Disclosure: Nothing to disclose.
Additional Contributors
Jack L Wilson, PhD, Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee Health Science Center College of Medicine
Jordan DR, Gilberg S, Mawn LA. The round-tipped, eyed pigtail probe for canalicular intubation: a review of 228 patients. Ophthal Plast Reconstr Surg. 2008. 24:176-80.
Penetrating lid trauma with extensive periorbital ecchymosis. A ringlike projectile was ejected from a pipe fitting under high pressure. The patient also experienced choroidal rupture and traumatic optic neuropathy.
Extramarginal upper lid laceration from blunt trauma in an infant. Such lacerations tend to follow relaxed skin tension lines.
Preoperative. This child had a dog bite injury with a double lower lid margin laceration, dehiscence of the lateral canthal tendon, and disruption of the inferior canaliculus.
Postoperative. The inferior canaliculus was repaired with bicanalicular stenting. Lateral canthus reattachment and repair of lid margin lacerations was performed.
Extramarginal upper lid laceration from blunt trauma in an infant. Such lacerations tend to follow relaxed skin tension lines.
Penetrating lid trauma with extensive periorbital ecchymosis. A ringlike projectile was ejected from a pipe fitting under high pressure. The patient also experienced choroidal rupture and traumatic optic neuropathy.
Preoperative. This child had a dog bite injury with a double lower lid margin laceration, dehiscence of the lateral canthal tendon, and disruption of the inferior canaliculus.
Postoperative. The inferior canaliculus was repaired with bicanalicular stenting. Lateral canthus reattachment and repair of lid margin lacerations was performed.
){kind=link}
){kind=link}
){kind=link}
){kind=link}