Chapter 35
EYELID AND LACRIMAL TRAUMA
Eyelid trauma has been a part of human history since ancient times. Sharp sticks, flint knives, and animal bites have commonly led to substantial eyelid trauma. Phillip of Macedonia, the father of Alexander the Great, suffered extensive eyelid wounds yet lived long enough to launch his son. Archaeological evidence suggests, however, that eyelid wounds could signal fatal trauma. Harold of England suffered eyelid trauma during the Battle of Hastings. The Bayeux tapestry and legend claim that he was killed by an arrow, which entered his skull through his eyelid.
Repair of eyelid wounds is documented in ancient Egyptian and Greek writings. Bandages and sutures were available when words were first written to describe surgical techniques.
In modern times trauma is still common because of sharp objects, animal bites, fighting, and burns; in addition newer sources such as high-speed missiles, and MVCs have also emerged. This chapter reviews the current management concepts in treating patients with trauma to the eyelids and lacrimal system.
EPIDEMIOLOGY (USEIR DATA)
Rate of lid and lacrimal system involvement among all serious injuries: 5%; breakdown:
• lacrimal laceration: 81%;
• periocular laceration: 70%;
• lid erythema: 19%;
• lacrimal obstruction: <1%.;
• lid deformity: <1%.
Age (years):
• range: 0–90;
• average: 23;
• rate of 0- to 9-year-olds among the total: 23%;
• rate of 10- to 19-year-olds among the total: 18%;
• rate of ≤60-year-olds among the total: 6%.
Sex: 77% male.
Place of injury:
• home: 37%;
• street and highway: 21%;
• recreation and sport: 11%;
• industrial premises: 8%;
• public building: 5%;
• school: 3%.
Source of injury:
• various blunt objects: 28%;
• various sharp objects: 16%.
• MVC: 14%;
• fall: 8%
• gunshot: 6%;
• fireworks: 4%;
• BB/pellet gun: 3%;
Globe involvement among the total: 61%.
Rate of animal bites among the total: 9%.
Through history and into modern times, clever devices have been developed to provide protection for the eyelids and eyeballs. From the hoplite helmet to shatterproof windshield glass, technology has continued to improve eye safety. In the 20th century, laws and regulations at the workplace have been very helpful; this tendency is not apparent in the home (see Chapter 4).
EYELID LACERATIONS
Pathophysiology
Eyelid trauma can be quite dramatic, and the evaluation of eyelid trauma requires a thorough understanding of the anatomy of the eyelid and the adjacent structures. The eyelid’s primary function is to provide protection to the eyeballs.
PEARL… Because globe injury and eyelid trauma commonly occur concurrently, any investigation of eyelid trauma must include to a detailed examination of the eyeballs.
PEARL… When orbital fat is present in the wound, an orbital injury has occurred.
The eyelid margin is in contact with both the tear film and the outside environment. The mucoepithelial junction is an important anatomic landmark.
The eyelid is also an important part of the tear pump. The action of the lid margin pushes tears toward the punctum for removal. Disruption of the eyelid margin may lead to an impaired tear pump. This can occur with notching of the eyelid margin or with traumatically induced laxity. The inability of the eyelids to properly move the tears may lead to:
• epiphora;
• dellen formation; or even
• corneal ulceration.
The canalicular system carries tears from the puncta to the lacrimal sac. Evidence suggests that the lower canalicular system is primarily responsible; however, in some people, the superior part of the system removes most of the tears.1
PEARL… Patients with canalicular laceration always require repair. It is impossible to determine preoperatively whether the superior or lower canalicular system is dominant in the injured individual.
The canalicular system is very close to the conjunctival surface. An extremely medial cutaneous eyelid laceration may not involve the canalicular system if the wound is superficial.
PEARL… A conjunctival laceration in the medial aspect of the eyelids probably involves the canalicular system.2,3
The levator muscle is the primary elevator of the upper eyelids. The levator aponeurosis is the tendon of the levator muscle. The levator muscle has numerous attachments in the eyelid, all of which may be involved with trauma. Insertions of the levator include:
• conjunctiva;
• superior tarsus;
• anterior tarsus;
• orbital septum; and
• skin.
The levator attaches to the conjunctiva at the superior fornix, the superior border of the tarsus through Müller’s muscle, and the anterior face of the tarsus through the levator aponeurosis. Attachments to the orbital septum and skin are also consistently found. Eyelid trauma can lacerate or contuse the levator muscle or stretch and break the levator aponeurosis.
Eyelid trauma can compromise the levator function. Lacerations or contusive trauma may lead to traumatic ptosis. The ptosis may persist for a variable period of time and often resolves spontaneously only long after the other manifestations of trauma have healed.
Traumatic ptosis caused by contusion often improves spontaneously.4 Characteristics of such a ptosis are:
• history of eyelid trauma;
• poor levator function; and
• slow but almost always full recovery.
The initial treatment for traumatic ptosis, which has been caused by contusion, is observation. It is not unusual to see complete recovery 6 months following the accident. If full recovery does not occur, exploration of the eyelid and repair of the ptosis are indicated.
Evaluation
The evaluation and diagnosis of eyelid trauma begin with a history and physical examination and observation. For the ophthalmologist, it is of paramount importance that a thorough eye examination be performed. Eyelid lacerations are often accompanied by severe globe injuries and retained orbital foreign bodies (see Chapters 24 and 36).5–7
PEARL… Dramatic eyelid injuries may conceal dangerous ocular, orbital, and/or neurologic injuries (see Chapter 10).
• Even very small eyelid lacerations may involve the canalicular system. A high index of suspicion is important when evaluating the medial eyelids. Medial conjunctival lacerations often involve the canalicular system. Probing the canalicular system is easily accomplished in the ER.
PEARL… For complex lacerations, irrigation of the lacrimal system with sterile saline can be performed. Saline exiting from the wound is a sure sign of canalicular laceration.
The levator muscle is evaluated by observing the excursions of the upper eyelids. Traumatic ptosis or mechanical ptosis may be documented. If possible, a lacerated levator aponeurosis should be repaired primarily. Mechanical ptosis, when seen without eyelid lacerations, may be due to:
• eyelid swelling;
• contusion to the levator aponeurosis;
• neurologic damage; and
• levator damage.
Without a laceration present, it is often wise simply to observe the ptosis for a period of time. Exploration of the levator muscle is not indicated unless an eyelid laceration and potential levator muscle or aponeurosis damage are observed.
Effective emergency evaluation of children is sometimes impossible in the ER (see Chapters 9 and 30). Probing and irrigation of a potentially lacerated canalicular system is contraindicated in the young or uncooperative patient. An examination under anesthesia is commonly needed to arrive at a definitive diagnosis.
PITFALL
Patient care should never be compromised for lack of an adequate examination.
Radiology has limited importance in the evaluation of eyelid trauma. An orbital CT scan should be ordered when the suspicion of a retained orbital foreign body is present (see Chapter 36).
Eyelid lacerations often occur due to animal bites.8,9 The history of an animal bite should be reported to the authorities so that the animal can be observed for rabies.7 Medical personnel may be required by local law to file the report of an animal bite injury (see in more detail later in this chapter).
Appropriate use of antibiotics, tetanus toxoid, and all prophylactic measures apply in case of eyelid trauma (see Chapters 8,9, and 28 and the Appendix).10
Timing
Eyelid margin lacerations do not require immediate repair. Injuries of inebriated patients, presenting at night or on the weekend, can be repaired when experienced personnel become available during “regular business hours.” After a thorough examination, antibiotic ointment and a patch will stabilize the patient until a definitive repair can be performed in 24 to 48 hours. It is usually not wise to delay the repair for over 48 hours.4
PEARL… Eyelid lacerations do not have to be repaired immediately.
Management
Eyelid margin lacerations are commonly seen in ERs.
• Simple eyelid margin lacerations can usually be repaired in the ER under local anesthesia (see Chapter 8). To perform an adequate repair, proper equipment, lights, and support personnel must be present.
• Children and uncooperative patients and those with more complex injuries must be repaired in the operating room under general anesthesia.
The anatomy of the upper and lower eyelids guides the techniques for repair. Traditionally, the eyelid has been described as having two layers:
• an anterior lamella, consisting of the skin and the orbicularis muscle; and
• a posterior lamella consisting of the conjunctiva and the tarsus.
The approximation of these lamellae forms the basis for eyelid repair. By meticulous and precise closure, the overall goal is to restore the eyelid’s:
• contour;
• function; and
• anatomy.
The eyelid has several anatomic structures that help to achieve the proper alignment:
• the eyelash line;
• the gray line; and
• the meibomian gland orifices.
The eyelash line is a consistent landmark, which will help with the proper suture placement and alignment of the eyelid. There are normally three linear rows of lashes on the upper eyelid and two linear rows of lashes on the lower eyelid.
PITFALL
Proper alignment of the eyelashes and proper orientation of the eyelashes are important. Suture imbrication of the eyelashes can lead to trichiasis once healing has occurred.
The meibomian gland orifices
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