Lid and Canalicular Laceration Repairs
R. Kevin Winkle, MD
PREOPERATIVE CONSIDERATIONS
Perform a complete exam to rule out open globe.
Repair globe if necessary, before repairing eyelid lacerations.
Assess tetanus status and order vaccination if indicated.
Always explore for canalicular lacerations when lid lacerations are present as trauma to the lid is often associated with canalicular avulsion injuries as well. This is particularly true in dog bite injuries and blunt lid trauma.
Lacerations medial to the punctum should be explored for canalicular injury.
Pass a probe through the upper or lower punctum and along the canaliculus.
If the probe is visible in the laceration, the canaliculus has been lacerated and requires repair (Fig. 23.1).
Repair canalicular and lid margin lacerations first, and then close additional lid wounds.
 FIGURE 23.1. A probe placed through the punctum is visible in the eyelid laceration, indicating a laceration of the canaliculus. |
CANALICULAR LACERATIONS
Equipment needed:
Canalicular stent of choice. Ritleng canalicular stents are excellent in trauma involving the lacrimal drainage system. Bicanalicular and monocanalicular stents are available.
High magnification loupes and an operating microscope.
Procedure:
Depending upon where the laceration is located, the nylon suture attached to the Ritleng stent may be passed through the punctum first without the introducer, or an introducer may be used. If there is a large separation between the cut ends of the canaliculus, then pass the suture and stent through the puncta into the lateral portion of the wound first, and then use the introducer to pass the stent through the proximal canaliculus into the nose (Fig. 23.2). This prevents inadvertent tearing of the often fragile tissue of the distal canaliculus when the introducer is rotated to pass downward into the nose.
Identify the cut end of the canaliculus.
The canaliculus typically has a whitish coloration compared to the background red and pink of the surrounding tissue, and inspecting for an apparent lumen is beneficial (Fig. 23.3). This color difference can help to identify the proximal canaliculus. Often the proximal canaliculus retracts, especially when the medial canthal tendon is ruptured.
An operating microscope and the use of cotton-tipped applicators or a lowpowered suction catheter help to facilitate the view.
0.3 and 0.5 Castroviejo forceps can be used to gently pull the tissue into view when the canaliculus has retracted, and often this is when the lumen can be seen in conjunction with its characteristic white coloration.
If the proximal end is not identified, perform the following steps:
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