Eyelid Lacerations
Jason Liss, MD
Paramjit K. Bhullar, MD
DISEASE DESCRIPTION
Eyelid lacerations can result from facial trauma and can be broadly categorized as follows: (Figure 20.1)
Partial versus full thickness
Margin-involving versus non-margin-involving
Lacrimal drainage system involving versus lacrimal drainage system sparing
MANAGEMENT OPTIONS
Depending on the mechanism of trauma, there may be injuries beyond the eyelid. Ensure that the appropriate workup has been completed.
Superficial lacerations may mask a deeper laceration, foreign body, or penetrating injury to the lacrimal drainage system, orbit, or globe.
Before laceration repair, a computed tomography (CT) of the brain, orbits, and face should be obtained if there is any history suggestive of penetrating injury or severe blunt trauma.
If the laceration is medial to the punctum, perform punctal dilation and probing with irrigation of the canalicular system to assess canalicular involvement.
Determine the appropriate setting for repair: operating room (OR) versus procedure room or at bedside.
Consider repair in the OR if there is
A need for additional surgery (ruptured globe, orbital or facial fracture, etc)
Significant eyelid tissue loss
Involvement of the lacrimal drainage system (except when uncomplicated)
Medial canthal tendon avulsion (suggested by excessive rounding, displacement, or laxity of the medial canthus)
Visible orbital fat in an eyelid laceration, suggesting penetration through the orbital septum. If there is fat protruding from an upper lid laceration, consider OR for evaluation of the levator muscle and tendon to determine whether levator repair is needed.
An uncooperative patient or any patient who cannot tolerate repair while awake
FIGURE 20.1. Clinical photographs demonstrating the various types of eyelid lacerations. A, Non-margin-involving laceration of the left upper lid. B, Margin-involving laceration of the right lower lid. C, Canalicular laceration of the right lower lid. D, Medial canthal tendon avulsion/full-thickness margin-involving laceration involving the left upper canaliculus.
FIGURE 20.1. (continued)
Consider repair in a procedure room or at bedside:
In very cooperative patient
For uncomplicated lacerations likely requiring no more than 1 hour of repair time
Young children will often require repair in the OR because of limited cooperation, unless under general anesthesia. An alternative is conscious sedation in a setting such as the emergency department.
INDICATIONS FOR SURGERY
Most eyelid lacerations are repaired to restore proper eyelid structure and function. The goal of the repair is to provide adequate protection of the ocular surface, facilitate lacrimal drainage, and maintain cosmesis. Given the excellent blood supply to the eyelids, primary repair is usually performed. Contaminated wounds, such as those from human or animal bites, may contain necrotic tissue requiring urgent debridement. Alternatively, contaminated wounds may be left open for delayed repair. Lid laceration repair, including lacerations that involve the lacrimal drainage system, may be delayed up to 3 days without significant negative effects.
Eyelid tissue tends to be quite resilient, so excision of seemingly necrotic tissue should be performed with great discretion and only when absolutely necessary. This is especially important in younger patients, because reduced tissue redundancy means a more significant risk of eyelid retraction.
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