History

Periocular trauma can occur as an isolated injury or as a small part of multisystem trauma. You must make sure that the patient’s cardiopulmonary and neurologic status is stable before you evaluate and treat any ocular or periocular injury ( Figure 13.1 ). Evaluation of the eye precedes evaluation of the soft tissue and bones. You must prevent further injury to the eye as a result of manipulation of the surrounding tissues.

Cardiac contusion caused by the seat belt following a motor vehicle accident. The patient’s other injuries included a severe eyelid laceration.

Try to obtain some history about how the injury occurred. A broad area of superficial involvement may initially look worse than a small puncture wound. The puncture wound may extend deeply, causing injuries to the eye, orbital contents, or brain, a much more serious situation than the superficial abrasion. If it appears possible that there was deep penetration into the orbit, try to determine what instrument caused the injury to give you some information about the depth of penetration and the possibility of the presence of a foreign body that may have broken off. Symptoms of diplopia or hypesthesia of the infraorbital nerve should suggest an orbital fracture. Always be skeptical about the history if alcohol was involved or if the patient is a child. Alcohol use has a way of distorting a patient’s perception of the facts. Children may not give an accurate history, fearing they may get in trouble with their parents ( Figures 13.2 to 13.4 ). Your examination helps you decide if the history is plausible and if imaging studies are necessary to rule out injury to deep tissues ( Box 13.1 ).

Unsuspected foreign body found in a laceration in a child injured at preschool.

( A ) Unusual conjunctival swelling in a 12-year-old boy with “no history” of trauma. ( B ) BB removed from conjunctiva. The boy later disclosed that he and a friend were playing with BB guns!

Anterior orbitotomy in a 3-year-old to remove a BB, shot by his brother.

Take a general medical history to make sure that the patient is able to tolerate local or general anesthesia. You need to know when the patient last ate or drank if you are considering general anesthesia. Inquire about recent tetanus injections.

Photographs

Take photographs of the patient before cleaning the wounds. These photographs should document the severity of the injury for medicolegal documentation. Occasionally, after repair, your patient may be unhappy with your best attempts to reconstruct the facial injuries. These photographs can remind the patient of the severity of the initial injury. In some cases, photographs may provide some legal defense of your efforts.

Eye

We won’t go into much detail about examining the eye. Remember that eye injuries commonly occur with facial trauma. As always, measuring the vision is an essential part of the eye examination. You must explain any acuity measurement that is not normal. This can be difficult if the patient is lethargic, intoxicated, or otherwise uncooperative. Remember to check the visual acuity on both sides. In an uncooperative patient, a vision of 20/20 in the right eye and 20/100 in the left eye is much more suggestive of an injury to the visual system than an acuity of 20/100 in both eyes. If you can’t explain the decrease in visual acuity as being caused by an injury to the eye itself, consider the possibility of damage to the optic nerve, or traumatic optic neuropathy. We discuss traumatic optic neuropathy in more detail in the section on facial fractures later in this chapter.

Eyelids

Next inspect the eyelids. Note the location, extent, and severity of injury to the soft tissues. Draw a diagram to describe the soft tissue injury. Develop a routine for examination of the soft tissue. Start with inspection of the continuity of the lid margins. Pay special attention to the lid margins medial to the puncta so you do not miss a canalicular laceration ( Figure 13.5 ). If you suspect a canalicular laceration, pass a 1-0 or smaller Bowman probe through the punctum and inspect the canaliculus. You may be surprised to know that most canalicular lacerations do not occur from direct trauma of the medial lid. Most are the result of an avulsion or tear that occurs when the lid or cheek is pulled laterally. This explains why the patient who has been punched with a fist on the zygoma can be seen with a lower canalicular laceration.

Canalicular lacerations of upper and lower eyelids.

Examine the anterior lamella of the eyelids. The presence of orbital fat in a wound means that the orbital septum has been violated and that there is a possibility of deeper orbital injury. Observe the upper eyelid movement to ensure that the levator muscle has not been damaged.

Next examine the more peripheral periocular areas. If a laceration has occurred near the trunk of the facial nerve, check for normal facial movements. If you suspect that the nerve has been damaged, primary nerve reanastomosis by a surgeon trained in this procedure may be required. If the injury is near the brow, check to make sure that the frontal nerve branch is intact. Clearly document any abnormality.

Soft Tissue Injuries

Soft tissue injuries are classified as:

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  Contusion

  
  
• ■
  

  Abrasion

  
  
• ■
  

  Avulsion

  
  
• ■
  

  Puncture

  
  
• ■
  

  Laceration

  
  
  
  
  • ■
    

    Simple or complex

    
    
  • ■
    

    Superficial or deep

  
  

Contusions and abrasions do not require surgical repair. Cleaning and use of topical antibiotics and ice are appropriate. Avulsions imply a tearing of the tissue, sometimes separating with loss of tissue. Tearing often occurs with injuries on pavement, but loss of tissue is extraordinarily rare. Remember that wounds usually spread open, making them look like tissue may be lost. Punctures are caused by long sharp objects that create small entrance wounds but may extend deeply. Lacerations are caused by sharp objects. Clean cuts or simple lacerations require only single-layer closure and heal with minimal scarring. Lacerations outside the orbital rims extending into the subcutaneous fat usually require a layered closure. Complex lacerations have extensive jagged edges that extend into deeper layers of tissue. These lacerations may require several hours of layered closure, but with good technique, the results can be spectacular ( Figure 13.6 ). When dealing with deep lacerations of the face, evaluate facial nerve function prior to injecting any anesthesia. Canalicular and lid margin lacerations require special techniques that you can master with some instruction and practice.

Complex facial lacerations caused by a dog bite. ( A ) Initial injury. ( B ) Final result after repair and scar maturation.

Preparation

Small, simple lacerations are usually repaired with local anesthesia in adults and children. Tissue glue (Dermabond, ethicon.com ) is available for repairing small lacerations without anesthesia, which is most helpful in children. More complex lacerations should be repaired with general anesthesia. Facial lacerations should be repaired within 12 to 24 hours. Operations for life- or vision-threatening conditions take priority over laceration repair. Fractures associated with facial lacerations are either repaired at the time of laceration repair or after 3 to 5 days when the facial swelling resolves. The specific timing for blowout fracture repair is discussed later. Although facial lacerations rarely become infected, prophylactic broad-spectrum antibiotics, usually a first-generation cephalosporin, are prescribed for 1 week.

In the operating room, the wounds should be injected with local anesthetic containing epinephrine. All foreign bodies should be removed from the wounds. Vigorous cleaning and irrigation should be performed to minimize the chance of infection and tattooing of the skin with foreign materials.

Anterior Lamellar Repair

Before repair of any laceration, explore the depths of the wound to ensure that deeper injury has not occurred. Any visible orbital fat means that the orbital septum has been violated ( Figure 13.7 ). Make sure that you are not dealing with a potentially more serious injury involving damage to the orbital contents or brain ( Figure 13.8 ). If the laceration occurs perpendicular to the orbicularis fibers and the wound is pulled open, placement of deep absorbable sutures in the muscle helps to approximate the wound edges without placing tension on the skin closure.

Any visible orbital fat means that the septum has been violated. Rule out injury to the eye, orbit, or brain and the possibility of the presence of a foreign body.

Deep orbital penetration through a small skin wound at the inferior orbital rim. ( A ) The patient had a small laceration and ecchymosis after falling on a tree branch. ( B ) Total ophthalmoplegia and no light perception vision were noted as a result of penetration of the branch through the orbit and into the brain.

Lacerations parallel to the orbicularis muscle do not require closure of the muscle layer. Placement of interrupted permanent skin sutures that bisect the wound in successive halves prevent the formation of a dog-ear (redundant tissue on one side of the wound noted at the completion of closure). A running suture can be used for longer straight lacerations, but this does not permit individual removal of sutures if any infection should occur. Suitable sutures for eyelid skin closure include 6-0 and 7-0 nylon or Prolene. Lacerations of the brow in thicker skin can be closed with 4-0 or 5-0 nylon or Prolene sutures. Blue 5-0 Prolene sutures are especially useful in the brow, where black sutures can easily be confused with eyebrow hairs. A layered closure can be used in the dermis or subcutaneous tissues to remove tension from the skin edges. Do not close the orbital septum; lagophthalmos may result.

Complex Laceration Repair

Complex lacerations have many jagged edges and extend into deeper tissue layers. Repair of a complex laceration is like building a jigsaw puzzle. First, you start with pieces of the puzzle that you can identify, the edges and corners, and put them together. Then you fill in the missing areas in the center of the puzzle, looking for less obvious details to guide you.

The steps of complex laceration repair are:

• 1.
  

  Clean and inspect the wound ( Figure 13.9A to C ).

  
  
  
  
  • A.
    

    Rule out deep injury.

    
    
  • B.
    

    Remove any foreign material.

    
    
  • C.
    

    Do not debride any tissue. It is surprising how well this tissue survives.

  
  

  
  

  
  

  

  
  

  
  

  Eyelid laceration resulting from an explosion of a bottle containing dry ice. Complex laceration repair series. ( A ) Upper eyelid and medial canthal lacerations. The eye is soft and filled with blood. ( B ) A large piece of glass penetrated the cornea. ( C ) Primary enucleation was performed. ( D ) A canalicular laceration was identified and repaired ( small arrow points to punctum; large arrows point to cut ends of canaliculus). ( E ) The posterior lamella and eyelid were repaired. ( F ) The anterior lamella was repaired last. ( G ) Nine months after repair with ocular prosthesis in place.

  
  
  
  
• 2.
  

  Repair the deep layer.

  
  
  
  
  • A.
    

    To begin the laceration repair, identify anatomic landmarks such as the eyebrow, lid margin, and canthus (see Figure 13.9D ).

    
    
  • B.
    

    Place deep sutures to reposition the anatomic landmarks in proper alignment.

    
    
  • C.
    

    In some cases, temporary tacking sutures of large caliber (3-0 or 4-0) can be placed full thickness through the skin to help with the orientation of tissues and take tension off the wound while deep layers are being closed. These temporary sutures are removed as the wound comes together.

    
    
  • D.
    

    Start with the deepest layers of closure first, including any posterior lamellar repair of the conjunctiva, tarsus, canthal tendons, or levator aponeurosis (see Figure 13.9E ).

    
    
  • E.
    

    Close the subcutaneous layer with buried absorbable long-lasting sutures such as 4-0 and 5-0 Vicryl or PDS sutures. In large lacerations extending onto the scalp, 3-0 PDS sutures are appropriate. Use a reverse-cutting needle for these closures. If you are unhappy with the position of a deep suture, replace it. The final skin closure cannot compensate for poor deep closure alignment.

    
    
  • F.
    

    Complete the deep closure before starting closure of the superficial layer.

  
  
  
  
• 3.
  

  Close the superficial layer.

  
  
  
  
  • A.
    

    Approximate the edges of the skin with interrupted sutures (see Figure 13.9F ).

    
    
  • B.
    

    Most commonly, 6-0 and 7-0 nylon sutures are used on the eyelids, and 4-0 and 5-0 nylon sutures are used in the thicker periocular skin.

    
    
  • C.
    

    You can use absorbable sutures such as 5-0 or 6-0 chromic sutures for the final skin closure (see Figure 13.9G ). You should always use absorbable sutures in children.

    
    
  • D.
    

    Use a topical antibiotic ointment such as erythromycin, placed over the wound.

    
    
  • E.
    

    Dressings are not necessary.

  
  

Suture removal should be done between 5 and 10 days after surgery. If you are removing sutures early, you may want to remove every other suture initially and have the patient return a few days later for removal of the remaining sutures. Superficial wound healing occurs within the first week or two. Scar maturation does not occur until 6 to 12 months after surgery. You need to be supportive during this period. Massage with vitamin E oil or other products (e.g., Mederma) is helpful. Several brands of silicone sheeting (e.g., ScarAway) are available to reduce raised scars on the face. Avoid revisions until all healing is complete and scars are flat and nonerythematous ( Box 13.3 ).

LID Margin Repair

Some lid margin lacerations are isolated minor injuries or are associated with large facial wounds (see Figure 13.9 ; Box 13.4 ). The technique for repair is the same in either situation. Repair begins with identifying the appropriate anatomic landmarks of the eyelid, especially the landmarks of the lid margin. The strength of the closure is in sutures placed in the tarsal plate. Eyelid margin eversion is necessary to prevent lid notching.

Eyelid margin repair includes:

• ■
  

  Injecting local anesthetic

  
  
• ■
  

  Aligning the lid margin

  
  
• ■
  

  Suturing the tarsal plate

  
  
• ■
  

  Suturing the lid margin

  
  
• ■
  

  Closing the skin

The steps of eyelid margin repair are:

• 1.
  

  Inject local anesthetic.

  
  
  
  
  • A.
    

    Repair can be done with local or general anesthesia.

    
    
  • B.
    

    Instill topical anesthetic drops and inject local anesthetic with epinephrine into the wound.

  
  
  
  
• 2.
  

  Align the lid margin: Use a 7-0 Vicryl vertical mattress suture passed through the meibomian gland orifices to align the lid margin. Keep this suture long for traction ( Figure 13.10A ).

  
  

  
  

  
  

  

  
  

  
  

  Lid margin repair. ( A ) Align the lid margin using a vertical mattress suture passed through the meibomian gland orifices. ( B ) Suture the tarsal plate using two or three interrupted sutures passed in a lamellar fashion. ( C ) Suture the lid margin using an additional vertical mattress suture anterior to the gray line. ( D ) Close the skin.

  
  
  
  
• 3.
  

  Suture the tarsal plate: Use two or three interrupted 5-0 or 6-0 Vicryl sutures passed in a lamellar fashion to align the tarsal plate. Traction on the initial lid margin suture helps with the positioning of your tarsal sutures (see Figure 13.10B ).

  
  
• 4.
  

  Suture the lid margin.

  
  
  
  
  • A.
    

    Go back to the lid margin and place an additional 7-0 Vicryl vertical mattress suture anterior to the gray line. The vertical mattress sutures should provide eversion of the lid margin wound (see Figure 13.10C ).

    
    
  • B.
    

    If you are unhappy with the alignment of the lid margin, replace the sutures.

    
    
  • C.
    

    An additional anterior lamellar suture (just distal to the eyelashes) can be used to help the alignment of the eyelashes (see Figure 13.10D ).

    
    
  • D.
    

    I prefer to use 7-0 Vicryl sutures for the eyelid margin. Traditional teaching suggests the use of 6-0 or 8-0 silk sutures, which should be left long and require removal later. The 7-0 Vicryl sutures can be cut on the knot and allowed to absorb.

    
    
  • E.
    

    Don’t tie the margin sutures very tightly because the tissue may die, resulting in a lid margin notch.

  
  
  
  
• 5.
  

  Close the skin.

  
  
  
  
  • A.
    

    The skin can be closed with an interrupted simple or vertical suture using permanent or absorbable sutures (see Figure 13.10D ).

    
    
  • B.
    

    If the wound seems to be under tension, you may want to place 5-0 Vicryl sutures through the orbicularis muscle before closing the skin.

  
  

Postoperative care is routine. Occasionally, the sutures rub against the cornea and require removal.

Diagnosis of Canalicular Laceration

Assume that the canaliculus has been cut if there is any injury extending close to the lid margin medial to the puncta of the eyelids ( Figure 13.11 ). If there is any question, confirm the presence of a laceration by passing a probe through the canaliculus. Canalicular lacerations may occur because of a laceration from direct trauma to the canaliculus or, as stated above, as a result of an avulsion from lateral tension on the eyelid. Direct laceration of the canaliculus is easier to fix than an avulsion-type of injury. Direct lacerations involve the middle portion of the canaliculus, making it easier to find and repair the ends of the lacerated canaliculus. Avulsion-type injuries generally tear the canaliculus close to the sac, making visualization of the proximal cut end of the canaliculus difficult. For these injuries, the operating microscope is helpful.

Suspect canalicular laceration if there is any trauma medial to the puncta. Note the probe in the torn edge of the canaliculus.

Remember, suspect a canalicular laceration when there is any laceration at or near the medial canthus of the upper or lower lid. Repair of the laceration without special attention to the canaliculus is likely to cause occlusion. Approximately 50% of young adult patients have tearing if one canaliculus is occluded. This percentage is lower for older adults because tear production decreases with age. The upper and lower canaliculi contribute nearly equally to the drainage of tears. In most patients, you should attempt to repair the lacerated canaliculus.

Repair of Canalicular Laceration

The goal of canalicular laceration repair is to appose the torn edges of the canalicular mucosa in anatomic alignment. If the wound is deep, the medial canthal tendon needs to be repaired. Use of the operating microscope is helpful for finding the cut ends of the canaliculus and for facilitating repair. The microscope not only provides excellent magnification and illumination but it also allows both you and your assistant to see the wound without bumping heads while working in a narrow space. Pass a silicone stent through the canaliculus as part of the reconstruction to prevent cicatricial changes from closing the canaliculus postoperatively.

Three intubation techniques are used to repair the torn canaliculus:

• ■
  

  Repair using bicanalicular intubation with nasolacrimal duct intubation using bicanalicular stent (Crawford, Catalano, or other types)

  
  
• ■
  

  Repair using bicanalicular intubation with the pigtail probe

  
  
• ■
  

  Repair with a monocanalicular stent

The first technique uses standard Crawford stents for intubation of the canaliculi and the nasolacrimal duct ( Figure 13.12A ). The second technique requires intubation of only the canalicular system using a pigtail probe (see Figure 13.12B ). Several types of monocanalicular stents are available (see Figure 13.12C ).

Three techniques for canalicular laceration repair. ( A ) Bicanalicular and nasolacrimal duct intubation with Crawford stents. ( B ) The pigtail probe technique for repair of canalicular lacerations, requiring intubation of only the canaliculi. ( C ) Monocanalicular stent being inserted into upper canaliculus.

Each technique has advantages and disadvantages. You are probably more familiar with intubation of the lacrimal system using Crawford stents. A disadvantage of this technique is that it is difficult to intubate through the duct into the nose using local anesthesia alone. As an alternative to nasolacrimal intubation, you can intubate only the canalicular system using a pigtail probe. The pigtail probe technique has two advantages. First, general anesthesia is not required, because no intubation of the nasolacrimal duct is performed. Second, rotation of the pigtail probe through an intact canaliculus shows you the cut proximal end of the canaliculus. The pigtail probe technique has some disadvantages. The probe only works if there is a true common canaliculus. In a small percentage of patients, the upper and lower canaliculi enter the sac independently. In these patients, the pigtail probe cannot be threaded through the system, and a Crawford stent or monocanalicular stent repair is necessary.

You may have been biased by older literature condemning the pigtail probe. Despite its poor reputation, the pigtail probe can be used successfully in all but a small percentage of patients. Intubation of the canaliculi with the pigtail probe is more difficult than using Crawford stents, but no retrieval of the stent in the nose is required. Try to learn both techniques ( Boxes 13.5 and 13.6 ).

Canalicular repair using Crawford stents includes:

• ■
  

  Identifying the cut ends of the canaliculus

  
  
• ■
  

  Passing the stent through the torn canaliculus

  
  
• ■
  

  Passing the stent into the nasolacrimal duct

  
  
• ■
  

  Suturing the pericanalicular tissue

  
  
• ■
  

  Passing the other stent through the nose

The steps of canalicular laceration repair using Crawford stents are:

• 1.
  

  Identify the cut ends of the canaliculus.

  
  
  
  
  • A.
    

    It is easy to identify the cut ends of the canaliculus if the lid margin itself has been directly cut. The mucosa of the canaliculus is visible as a white or pink ring of mucosa ( Figure 13.13 ). It is much more difficult to identify the cut end of the canaliculus if it has been avulsed at the lacrimal sac. A microscope is helpful in all canalicular laceration repairs but especially for avulsions because the laceration is deep in the medial canthus, often at the common canaliculus.

    
    

    
    

    
    

    

    
    

    
    

    Lacerated canaliculus: note the ring of mucosa on the proximal side of the lacerated canaliculus ( arrow ).

    
    

  
  
  
  
• 2.
  

  Pass the stent through the canaliculus.

  
  
  
  
  • A.
    

    Thread the stent through the punctum and out the distal end of the lacerated canaliculus ( Figure 13.14A ).

    
    

    
    

    
    

    

    
    

    
    

    Canalicular laceration repair with Crawford stents. ( A ) Pass the stent through the cut end of the canaliculus and into the lacrimal sac. ( B ) Intubate the opposite canaliculus and nasolacrimal duct. ( C ) Reinforce the medial canthal tendon with a 5-0 Vicryl suture. ( D ) Approximate the canalicular mucosa using sutures in the canalicular mucosa or adjacent tissues. ( E ) Use additional sutures in the orbicularis muscle as required to reinforce the wound. Suture the skin. Tie the stents in the nose.

    
    
    
    
  • B.
    

    Next, thread the stent to the proximal end of the canaliculus.

  
  
  
  
• 3.
  

  Pass the stent down the nasolacrimal duct (see Figure 13.14B ).

  
  
  
  
  • A.
    

    This step is similar to all nasolacrimal duct probings. If you are intubating an adult, it is helpful to bend the probe of the stent into a curve to maneuver around a prominent brow. Intubation of adults requires somewhat more manipulation than intubation of children.

    
    
  • B.
    

    Retrieve the stent and pull it out of the nose (use either an Anderson–Hwang grooved director or a Crawford hook; see Chapter 10 for tips on this technique).

    
    
  • C.
    

    Repeat for the opposite canaliculus (see Figure 13.14B ).

  
  
  
  
• 4.
  

  Suture the pericanalicular tissue around the stent.

  
  
  
  
  • A.
    

    If the laceration is at the junction of the canaliculus and the sac, it is worth using additional 4-0 Vicryl sutures (P-2 needle) to reinforce the medial canthal tendon before suturing the pericanalicular tissues (see Figure 13.14C ).

    
    
  • B.
    

    Ideally, the mucosal edges of the cut canaliculus should be apposed with suturing. It is not necessary to sew the mucosal edges together, but you should suture the pericanalicular tissue, bringing the mucosal edges together as much as possible. Two or three 6-0 or 7-0 Vicryl sutures are used for this purpose (see Figure 13.14D ). The difficult part of the procedure is over at this point.

  
  
  
  
• 5.
  

  Tie the stents.

  
  
  
  
  • A.
    

    Tie the stent in the nose. Be careful not to tie the knot too high so that it retracts into the nasolacrimal duct.

    
    
  • B.
    

    Be careful not to tie the stent too low so that the knot hangs out of the nose.

  
  
  
  
• 6.
  

  Suture the skin.

  
  
  
  
  • A.
    

    The skin can be sutured with either an absorbable suture or a permanent suture, usually 6-0 or 7-0 in size; I generally use a 6-0 chromic suture (see Figure 13.14E ).

  
  
  
  
• 7.
  

  Apply topical antibiotic ointment.

Canalicular laceration repair using a pigtail probe includes:

• ■
  

  Passing the pigtail probe

  
  
• ■
  

  Threading a 6-0 nylon suture through the canalicular system

  
  
• ■
  

  Passing the stent through the canalicular system

  
  
• ■
  

  Suturing the pericanalicular tissue

  
  
• ■
  

  Tying the nylon suture

  
  
• ■
  

  Suturing the skin

The pigtail probe technique has been useful for me in many patients. Initially, the technique is somewhat more complex than nasolacrimal duct intubation. Remember that you do not need to use general anesthesia because you do not intubate the nasolacrimal duct.

The steps of the canalicular laceration repair using a pigtail probe are:

• 1.
  

  Pass the pigtail probe ( Figure 13.15A ).

  
  
  
  
  • A.
    

    Use the pigtail probe with a closed needle eye, not an open hook, as was used several decades ago.

    
    
  • B.
    

    Choose the end of the pigtail probe that corresponds to the direction of rotation required. The curves on the ends of the pigtail probe are opposite in direction.

    
    
  • C.
    

    Place the tip of the pigtail probe through the intact punctum and rotate it through the normal canaliculus to the medial canthus. At this point, the handle of the probe should be oriented vertically perpendicular to the coronal plane of the patient.

    
    
  • D.
    

    At the medial canthus, the probe should go posterior to the anterior limb of the medial canthal tendon. You know that you are in the correct position if you lift the probe toward the ceiling of the operating room and meet resistance at the canthus.

    
    
  • E.
    

    Use gentle pressure to guide the pigtail probe through the common canaliculus. The probe should emerge through the cut proximal end of the canaliculus without exerting much pressure.

    
    
  • F.
    

    If the probe does not pass easily, try threading the probe through the cut proximal end of the other canaliculus (you lose the advantage of not having to find the canaliculus). If this doesn’t work, switch to a Crawford or Monoka monocanalicular stent. You have encountered one of the few patients who does not have a common canaliculus.

  
  

  
  

  
  

  

  
  

  
  

  Canalicular laceration repair with the pigtail probe. ( A ) Choose the appropriate curve of the probe (different curves on each end). Note the closed needle eye. Enter the normal punctum and rotate the probe posterior to the medial canthal tendon. The probe emerges from the cut end of the canaliculus. Thread a 6-0 nylon suture through the eye of the probe. ( B ) Rotate the 6-0 nylon suture through the canaliculus. ( C ) Thread the suture though the remaining canaliculus and punctum. Thread 25 mm of stent material over the suture. Grasp the stent over the suture with a smooth forceps and pull the opposite end of the suture to rotate the stent in place. ( D ) The stent is threaded through the remainder of the cut canaliculus and punctum. Repair the pericanalicular tissues as in Figure 13.14 . Tie the 6-0 nylon suture with the knot retracting into the stent. ( E ) Rotate the stent ring, placing the knot in the canaliculus. Close the skin.

  
  
  
  
• 2.
  

  Thread a suture through the canalicular system (see Figure 13.15A and B ).

  
  
  
  
  • A.
    

    Thread a 6-0 nylon suture (no needle) through the eye of the probe (see Figure 13.15A ) and rotate the probe out of the intact canaliculus (see Figure 13.15B ).

    
    
  • B.
    

    Pass the pigtail probe into the punctum of the torn canaliculus and out the distal end of the cut canaliculus. Thread the suture through the eye of the needle and rotate the probe out the punctum.

    
    
  • C.
    

    At this point, the 6-0 nylon suture is through the upper and lower canaliculi.

  
  
  
  
• 3.
  

  Pass the stent through the canalicular system (see Figure 13.15C ).

  
  
  
  
  • A.
    

    Cut a piece of silicone tubing 25 mm in length (for children, slightly shorter).

    
    
    
    
    • (1)
      

      This tubing can be broken off from a Crawford stent or can be ordered separately (Storz E4251). The silicone stent measures 0.125 mm (inner diameter) by 0.250 mm (outer diameter).

      
      
    • (2)
      

      Stent material is also available with a suture prethreaded (FCI Ophthalmics, S1–1900, FCI-ophthalmics.com ).

    
    
    
    
  • B.
    

    Use your fingers and a smooth forceps to thread the piece of stent over the nylon suture.

    
    
  • C.
    

    You now pull the suture and the stent through the canaliculus. To do so, grasp the silicone stent tightly with a smooth forceps, squeezing the suture within the stent.

    
    
  • D.
    

    Pull the opposite end of the 6-0 nylon suture and guide the piece of stent material into the punctum of the intact canaliculus. As you pull, the suture and the stent travel through the canalicular system and out the cut canaliculus (see Figure 13.15C ).

    
    
  • E.
    

    Again, guide the stent through the cut end of the canaliculus and out the punctum. The canaliculi are now intubated.

  
  
  
  
• 4.
  

  Suture the pericanalicular tissue.

  
  
  
  
  • A.
    

    Use the same technique as that described above for suturing the pericanalicular tissue to appose the mucosa of the cut canaliculus. You may want to place a small hemostat or “bulldog” clamp on the ends of the nylon suture to secure it while you repair the canaliculus.

  
  
  
  
• 5.
  

  Tie the nylon suture.

  
  
  
  
  • A.
    

    Tie the 6-0 nylon suture with three single throws tight enough to pull the knot into the stent but not so tight as to kink the circle of stent that you have created. Cut the tails of the knot short so they retract in the tubing (see Figure 13.15D ).

    
    
  • B.
    

    Rotate the tube, moving the knot out of the palpebral fissure into the canaliculus.

  
  
  
  
• 6.
  

  Suture the skin.

  
  
  
  
  • A.
    

    Use a technique similar to that above to suture the skin (see Figures 13.15E and 13.16 ).

    
    

    
    

    
    

    

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