3 Traumatic Eyelid Laceration
Traumatic eyelid lacerations are a common condition seen by just about every ophthalmologist, plastic surgeon, and emergency room physician. Despite the fact that each case is unique and the severity of injury is varied, a thorough understanding of anatomy and consideration of a few basic principles can help maximize outcomes. This chapter will review some essential steps in the evaluation and treatment of eyelid lacerations.
Anatomical repair resulting in maximum aesthetic and functional outcome. 1
Eyelids that adequately protect the eye, lubricate the cornea, and allow for optimal vision.
Creation of a stable eyelid margin, adequate vertical eyelid height, adequate eyelid closure, and development of an epithelized internal surface.
Cosmesis and symmetry.
Primary repair of traumatic eyelid lacerations as close to the time of initial injury as possible can optimize results. Increased blood flow, release of cytokines, and interruption of normal lymphatic drainage channels lead to post-traumatic edema that makes tissue planes difficult to identify and closure more challenging. Delay of repair until after formation of scar and granulation tissue has begun can likewise result in unsatisfactory closure. Should other circumstances preclude immediate intervention however, delayed repair may result in increased complications. 2 In such instances, the area should be cleaned, kept lubricated with ointment, and covered with a loose non-stick dressing.
Eyelids that protect the globe, lubricate the cornea, and do not obstruct vision.
An aesthetically favorable result.
3.4 Key Principles
No two traumatic eyelid lacerations are the same and the severity can vary widely. Several key principles in the approach to all traumatic eyelid lacerations can be utilized, and adherence to these principles can go a long way to maximizing outcomes. Life-threatening injuries should be ruled out and the patient should be stabilized prior to addressing ocular and adnexal injuries. Ocular injuries should be assessed and eyelid repair should be deferred in the setting of open globe injuries. Fractures, if operative, should be repaired prior to soft tissue repair. To avoid complications related to cicatricial lagophthalmos, the tension of closure should be horizontal and vertical traction should be minimized. Anatomical canthal fixation should be maintained when possible. When used, free grafts cannot be utilized for both anterior and posterior lamella. Canalicular repair should be attempted when it is reasonable to avoid epiphora in the future. Traumatic canalicular lacerations are often associated with medial canthal tendon injury, and bicanalicular silastic intubation in this setting can reinforce anatomical canthal fixation. A consideration in the pediatric population is the potential for amblyopia—young children with damage to the levator and resultant ptosis should be monitored for development of amblyopia.
Eyelid lacerations in a systemically stable patient.
Cardiopulmonary or neurologic instability.
Other grave bodily injuries requiring more urgent repair.
Lack of equipment or facilities to properly carry out the repair.
3.7 Preoperative Preparation
Prior to surgical repair of an eyelid laceration, a thorough systemic and ocular exam should be performed. Grave cardiopulmonary and neurologic injuries should be stabilized prior to repair of ocular and adnexal tissues. An accurate history including timing and nature of the injury should be obtained. Care should be taken to illicit information that may suggest foreign bodies, chemicals, or animal bites. If there is an animal bite, the rabies vaccination status of the animal should be determined. 3 , 4 If a foreign body is suspected, radiographic imaging with plain films, CT, or MRI should be obtained. Suspicion for an intraorbital or intraocular foreign body should be suspected by the presence of free air. 5 Questions aimed at differentiating between blunt and penetrating injuries should be asked.
Next, evaluation of the face looking for evidence of foreign bodies, missing tissue, or penetrating wounds is performed. Proper visualization of the full extent of wounds is often difficult due to obscuration by blood, debris, or hair as well as patient tolerance. 3 Gentle cleaning with sterile saline should be carried out and patient tolerance can be aided by light sedation or local infiltrative anesthesia.
A complete ocular exam, including a dilated fundus exam is required. Ruptured globes, hyphema, angle recession, and retinal detachments have all been associated with eyelid trauma. If a ruptured globe is present, all repairs of the eyelids should be deferred and manipulation of the surrounding periorbital tissue discontinued. 1 , 3 , 4
Thorough evaluation of the eyelids noting lacerations, tissue avulsion, foreign bodies, ecchymosis, and abrasions can be performed once the globe has been identified as stable. The presence of orbital fat may suggest a deep injury with potential trauma to the levator muscle (Fig. 3.1). In such cases, a traumatic ptosis may be present. 4 Medial eyelid injuries and dog-bite injuries (in children in particular) can be associated with injury to the lacrimal system and canalicular probing/irrigation should be performed to ascertain the extent of injury. 6 Though the lower canaliculus is most commonly involved, simultaneous globe injury has been found to be more common with upper canalicular involvement. 7 Rounding of the canthal angles or shortening of the palpebral fissure suggests canthal tendon injury or avulsion. 1 Assessment of the integrity of the medial and/or lateral orbital walls should be carried out and fractures should be repaired, if necessary, prior to canthal reconstruction. 8
Debridement of all foreign materials should be carried out to maximize wound healing and minimize infection and inflammation. Due to the excellent blood supply of the eyelids, often little to no debridement of eyelid tissue is necessary, and even damaged or avulsed tissue may be viable. 4 Thorough irrigation using sterile saline should be carried out for all contaminated wounds or noncontaminated wounds more than 6 hours old. 3
Once a complete examination of the injury has been performed, attention should be turned to deciding the optimal timing and setting for the repair. Factors to consider include the anticipated length of time needed, whether cardiopulmonary monitoring would be required, what sort of anesthesia might be required, and will there be adequate space, lighting, tools, and instrumentation available to accomplish the repair. Understanding and anticipating these factors can aid in the choice to perform the repair at bedside in the Emergency Department or inpatient floor, the procedure room, or in the operating room.
Once the decision on the timing and location of repair is made, consent should be obtained from the patient, next of kin, or individual with power of attorney, and communication and coordination with any other medical team should proceed.