Eyelid trauma ranges in complexity, but its inherently unexpected nature demands clinically meticulous examination and repair. A thorough history, if the patient is able to comply, is important to understand the etiology and associated risks of the trauma, as well as the underlying conditions that may complicate wound repair and healing. In the trauma setting, acquiring social history is imperative. Is the trauma due to suspected abuse or gangrelated danger? Certain domestic and peer-related situations may require urgent security or policerelated intervention. Was a foreign body involved? Metal, glass, organic matter, or other material may remain deeply or superficially embedded within the wound. If the patient is not up-to-date with vaccinations, tetanus vaccine is required in cases involving metallic penetration. Consideration of rabies status should be given when there is concern for animal exposure. Was the source of trauma blunt or sharp? Blunt or sharp trauma may fracture orbital bones, in some cases despite minimal overt signs of skin trauma. Imaging is frequently necessary. A sharp source may result in missing tissue or may have penetrated deeper than initial examination reveals. In such cases, thorough wound exploration at the time of repair is critical to rule out an occult foreign body. Does the patient believe vision was affected? A thorough globe examination is imperative in all cases, including a careful anterior and posterior segment examination to rule out occult ocular injuries or intraocular hemorrhage. Does the patient report double vision? Orbital fracture is a likely possibility, but orbital foreign body and other etiologies must be considered and orbital computed tomography imaging is mandatory. Conditions that could compromise wound-healing such as smoking, diabetes, or chemotherapy, may push the clinician toward extra antibacterial coverage and more frequent wound checks. Medical history of poor coagulation or anticoagulants should warn the clinician that wound repair may require additional hemostatic maneuvers. Throughout the course of discussion with the patient, the clinician should be alert for signs of trauma to the brain or other sustaining organs; has the patient been properly examined for systemic injury?

After ruling out life-threatening injuries, ruptured globe and sight-threatening retrobulbar hemorrhage, examination of the periocular trauma patient begins with an external survey of the face; single or multiple lacerations may be present unilaterally or bilaterally, including the eyelid and eyebrow. Facial nerve injury may be present. Vision and intraocular pressure should be assessed, as should the anterior and posterior segments. Extraocular muscle movement should be carefully examined. As the patient’s pupils are dilating, the superficial trauma can be more closely detailed. In the case of eyelid lacerations, integrity of the eyelid margin, medial and lateral canthal tendons, nasolacrimal system, and orbital septum should be noted. Coordination with other specialties for repair of all injuries should be attempted whenever possible. Even if eyelid injuries could be repaired at the bedside, if the patient is going to the operating room for other procedures, eyelid repair under the planned anesthesia may be preferable.

Consent is the first step toward repair. The patient or appropriate representative should be consented with the discussion of risks including hemorrhage, infection, scarring, nerve injury, ptosis, brow ptosis, brow cilia or eyelash loss, the potential need for additional surgery, and the risk of visual loss or ocular penetration.

Prior to repairing periocular lacerations, arrange a sterile, organized procedure space. Betadine solution (diluted to 5% so as not to irritate the ocular surface tissues) should be used for cleansing the periocular area and sterile towels for isolation of the field. Anesthetic eye drops and local anesthetic injection should be present both preprocedurally and on the field. A mixture of long and short acting injectable anesthetic is recommended, such as 0.75% bupivacaine mixed 1:1 with 2% lidocaine with 1:100,000 epinephrine. In addition to the instruments for repair, which include fine toothed forceps, needle holder, suture scissor, and corneal protective shield, the tray should include sterile cotton tipped applicators, sterile gauze, and lacrimal irrigation cannula, punctal dilator, and Bowman lacrimal probe. A fine, curved mosquito hemostatic forceps and a Desmarres retractor may be useful when gently exploring a shelved or unexpectedly deep wound. Each laceration should be thoroughly explored, irrigated, and cleaned with sterile saline or dilute betadine solution prior to wound closure. Tissue that appears loosely attached or poorly perfused in the periorbital area should generally not be debrided, as this tissue may be critical for the repair and is highly likely to reperfuse given the vascularity of the eyelid region. Wound repair should align natural anatomic planes without distorting the eyelid margins, causing eyelid retraction or lagophthalmos. Running sutures are generally avoided, allowing for the removal of individual sutures in case of infection.

Antibiotic ophthalmic ointment is applied to the wound at the end of the procedure, with topical and oral antibiotic generally recommended for 1 week after repair. A patch is avoided if possible, as the patient’s ability to see their wound may allow for early identification of wound infection.