Jacqueline Carrasco

BASICS

DESCRIPTION

• Eyelid lacerations occur 3 ways: Sharp trauma (e.g., pencil), blunt trauma (e.g., fist), or diffuse trauma (e.g., motor vehicle accident). Lacerations can affect 3 regions of the eyelid.

– Non-marginal eyelid

– Marginal eyelid

– Canalicular system, with or without avulsion of medial canthal tendon

EPIDEMIOLOGY

Prevalence

• 25% of eyelid trauma affects the margin (1)

• 15% of eyelid trauma involves the canaliculus (1)

RISK FACTORS

• For canalicular lacerations:

– Average age is 24 years (2)

– 80% are males (2)

GENERAL PREVENTION

• Work or recreational spectacles

• The glasses or goggles should say “ANSI Z87.1” This means that they meet the safety standards of the American National Standards Institute.

• See OSHA (Occupational Safety and Health Administration) and ASTM (American Society for Testing and Material) for other work and recreational eye protection standards.

PATHOPHYSIOLOGY

• Sharp trauma directly tears the eyelid skin, margin, or canaliculus. Many sharp objects have been reported to be the cause, including finger, nail, scissor, door handle, tree branch, fishing pole, and glass bottle.

• Blunt and diffuse trauma tears the skin and margin by traction. Sudden lateral displacement of the eyelid ruptures the medial canthal tendon and canalicular tissue. This can be the case with dog bites.

COMMONLY ASSOCIATED CONDITIONS

• 44% of eyelid trauma is associated with injury to the globe. (1)

• 25% of patients with canalicular lid laceration have globe injury (2).

• 65% of patients with canalicular lid laceration have associated injury including: (2)

– Globe rupture

– Facial fractures

– Optic neuropathy

– Retinal detachment

– Head trauma

DIAGNOSIS

HISTORY

• Ophthalmology consult can be obtained once life-threatening injuries are dealt with.

• Obtain details of how and when injury occurred. Understanding the mechanism may point to further injuries such as an occult orbital foreign body.

• Prior visual status

• Tetanus status

PHYSICAL EXAM

• Full ocular examination to rule out ruptured globe or suspected orbital or ocular foreign body.

• Measure length of laceration.

• Estimate depth, that is, full thickness versus partial thickness.

• Determine if laceration involves the margin.

• Look for prolapsed orbital fat which could indicate septum violation and levator muscle injury.

• If the laceration is medial to the puncta, canalicular involvement has most likely occurred.

DIAGNOSTIC TESTS & INTERPRETATION

Imaging

Initial approach

Small lid lacerations, as with a puncture site, may indicate possible occult orbital foreign body. If history and examination are suspects, consider CT scan without contrast of orbits, thin cuts, axial and coronal, to help rule out foreign body.

Diagnostic Procedures/Other

To test whether or not the canalicular system has been injured, an ophthalmologist may perform a probing and irrigation of the canalicular system.

TREATMENT

MEDICATION

First Line

• Tetanus should be up to date.

• Oral antibiotics for lid lacerations are anecdotally driven. If used, a first generation cephalosporin is recommended. (3)

• Lid lacerations due to animal or human bites should be treated prophylactically with antibiotics. (4)

ADDITIONAL TREATMENT

Issues for Referral

• If lid margin or canalicular system is involved, refer to ophthalmic surgeon. Keep laceration moist with wet dressing if eye is not ruptured.

• Often the lacerated area may appear to have missing tissue because of skin and orbicularis muscle contraction. Only rarely is there tissue loss.

• If there is tissue loss, more complicated repair is indicated. These cases should be referred to an oculoplastic specialist.

SURGERY/OTHER PROCEDURES

• Repair can be done, depending upon the extent of laceration, in a small procedure room or in the operating room under monitored anesthesia care or general anesthesia.

• Surgery and treatment for ocular injury should precede eyelid repair.

• Repair should be done within 24–48 hours (5)

• Non-marginal repair depending upon depth may include a layered closure with 5–0 or 6–0 Vicryl and skin closure with 6–0 plain or fast gut.

• Marginal repair should be referred to an ophthalmic surgeon for closure.

• Canalicular involvement by an ophthalmic surgeon or oculoplastic specialist may utilize bi-canalicular intubation with Crawford tubes, pigtail probe, or monocanalicular stents, such as a Mini-Monoka tube.

IN-PATIENT CONSIDERATIONS

Admission Criteria

Ruptured Globe

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Small strip of antibiotic ointment should be placed over sutured wound 2–3 times daily. Depending upon the extent of wound, patient should be seen for follow-up 3–7 days following repair.

PATIENT EDUCATION

Patient should be educated about the signs of infection: Redness, swelling, and pain.

PROGNOSIS

Typically very good. Once the wound is closed, satisfactory functional and cosmetic results can be achieved.

COMPLICATIONS

• Infection

• Tearing

• Trichiasis

• Lagophthalmos and corneal exposure

• Dislodged silicone stent

• Notched eyelid margin

• Note: Patients may need further surgeries to repair symptomatic eyelid deformities

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