Marian Pauly
Dr. Marian Pauly received her Master’s Degree in Ophthalmology from University of Kerala, India and later she underwent for 2 years fellowship in Orbit and Oculoplasty from the prestigious Sankara Netralaya, Chennai, India. She is a life member of Oculoplastic Society of India. She is the recipient of Dr Gangadhara Sundar Award for young Oculoplastic Surgeon as well as Jayaben Chamanlal Shah Gold Medal for Best Outgoing Sub-Specialty Fellow. Currently she is practicing in Giridhar Eye Institute, Kerala, India
The most important function of the eyelid is to protect the globe. Therefore, eyelid trauma has to be managed in a very meticulous manner to avoid damage to eyeball.
History
A thorough history is important as to the cause of injury. Road traffic accidents, machinery and intentional assaults can cause injury to the eyelid. History regarding the time, date and site of injury is important in deciding the management as well as medicolegal aspects. Injury to the surrounding structures should be ruled out by asking the history of epistaxis, double vision, decreased vision, numbness along infraorbital region and difficulty in opening the mouth.
Examination
Before evaluating the localised injury to the eyelid, the general medical status of the patient has to be evaluated by looking at ABC (airway, breathing and circulation) [1, 2]. Patients with life-threatening emergencies have to be managed immediately by a specialised trauma team before proceeding to the management of eyelid.
Complete ophthalmological evaluation has to be done which includes visual acuity, pupillary reaction, applanation tonometry if the globe is intact and dilated fundus evaluation. In the absence of signs of intraocular injury/penetrating injury, management of eyelid injury can be planned.
Photograph and drawings of the injury are important chart documents.
Examination of Eyelid Injury
Irrigate and explore (Fig. 11.1a, b): Irrigate the wound thoroughly with cold saline after putting the topical anaesthetic agent, and remove all foreign materials and blood clots and document the site, size and shape of injury.
Fig. 11.1
(a) On exploration, patient had levator and canalicular injury. (b) On exploration, patient had levator and canalicular injury
Laceration involving the lid margin needs special attention. Injury near the medial and lateral canthus can have associated canthal tendon injury and canalicular injury.
Look for any loss of tissue. If tissue loss is present, tissue transfer/mobilisation has to be planned preoperatively.
Look for the presence of the fat in the wound. It indicates injury to the levator muscle/septum [3, 4]. Check the levator function by asking the patient to look up and down after occluding the frontalis action. Change in the lid contour also denotes levator injury/avulsion.
Look for any signs of infection. If infection is present, delay the wound repair till infection subsides.
Laboratory and Radiologic Evaluation (See Sect. “Investigations” in Chap. 2)
Timing of Repair
The timing of eyelid repair is flexible. In the toxicated or poorly cooperative patient, a prudent delay until the patient is fully manageable is often indicated. The delay may improve the overall chance of success and patient safety.
If the patient is presenting within 24 h of injury, primary repair can be done [4] which will improve the functional cosmetic results. Delayed primary repair is done when there is marked lid oedema or infection or when the patient presents after 24 h of injury [3, 5]. This is performed after 3–4 days. During this waiting time, cold compresses, systemic antibiotics and anti-inflammatory agents have to be administered.
Basic Surgical Principles
- 1.
Re-approximate the tissue as accurately as possible.
- 2.
The closure should be done with minimal tension.
- 3.
Obliteration of dead space.
- 4.
Layered repair.
- 5.
Good lighting and haemostasis.
Anaesthesia
Local anaesthesia/general anaesthesia.
Sustained haemostasis with infiltration of 2 % Xylocaine with adrenaline.
Monitored anaesthetic care is preferred.
Regional anaesthesia is the most effective approach for laceration repair since it minimally distorts tissues and will provide profound anaesthesia to large areas [6]. Injection of the infraorbital, supraorbital, infratrochlear and supratrochlear nerves is adequate for the repair of most lacerations involving the eyelids, lacrimal drainage system and periorbital soft tissue.
Common Clinical Scenarios
Superficial/Deep Laceration Not Involving the Eyelid Margin (Fig. 11.2)
Fig. 11.2
Deep laceration involving the eyebrow
This can be managed by a simple closure/layered closure. 3-7 absorbable sutures are used for deeper tissues, and the skin is sutured with 3-7 silk/nylon/plain gut. Undermine the edges, if the wound is under tension. Rounded defects can be converted to elliptical defect before suturing, to avoid dog ears. The knots should be buried, and the suture is placed partially in the dermis to close the subcutaneous tissue.
Simple interrupted sutures are adequate, but horizontal/vertical mattress sutures are needed if the wound is under tension. The septum should be left unsutured both to avoid postoperative lagophthalmos and to lessen the effects of postoperative haemorrhage. It should not be closed or incorporated into deeper or superficial sutures. The skin sutures are removed in 5–7 days time.
Fibrin glue or cyanoacrylate glue can be used in dry clean wounds. The glue will disintegrate in 3–5 days time. Antibiotic ointments are avoided as it can facilitate the early disintegration of glue. It should not be used in ragged, stellate, contaminated and crush wounds [7–10].
Antitension taping (Fig. 11.3a, b) can be used in wounds involving only the skin which will approximate the skin edges and prevent the formation of a wide scar.
Fig. 11.3
(a) Small superficial laceration involving only the skin managed with antitension taping (before). (b) Small superficial laceration involving only the skin managed with antitension taping (after)
Lacerations Involving the Eyelid Margin
Exact repair of the lid margin is critical to avoid notching or margin discontinuity which can cause functional and cosmetic problems. The first step is to identify the tarsus and lid margin landmarks like the grey line, the meibomian gland orifices and the lash line. If the wound is ragged, freshening the edges with a scalpel blade may aid in structure recognition and wound apposition.
Using toothed forceps or skin hooks, the edges are brought together to allow assessment of tension on the wound. If the wound is tight, canthotomy or cantholysis is done to decrease the tension on the wound edges.
First align the lid margin by passing a suture through the meibomian gland orifice on both edges of the cut 2 mm from the edge, and look for the alignment. If the alignment and wound tension is adequate, pass a vertical mattress suture [13] and keep the ends long. This long ends can be used as traction suture for further steps.
Align the tarsal plate with 5–0 Vicryl suture. The suture should pass through 90 % of the tarsal plate, and the knots should come on the anterior side [14]. Full-thickness tarsal sutures are avoided as it can erode the conjunctiva to cause suture keratopathy. Two sutures are taken in upper lid whereas single suture in the lower lid. These tarsal sutures support the lid and prevent a sag in the lid margin which may lead to a notch.
Complete the lid margin suturing by taking sutures along the grey line and lash line. All the knots should come anterior and tied in the skin suture so that the long ends will not irritate the ocular surface. The grey line suture can be an optional suture. The wound edges should be everted. Do not tie the margin sutures very tightly because tissue may die resulting in lid margin notch. The orbicularis and skin are sutured with simple interrupted sutures. The lid margin sutures are removed after 10 days (Fig. 11.4a–c).
Fig. 11.4
(a) Laceration involving eyelid margin of both the upper and lower lid. (b) Sutures are tied anteriorly. Long ends can be trimmed. The upper lid sutured with 6/0 silk, whereas the lower lid with 6/0 nylon. (c) Two weeks post-op view after suture removal
In children (Fig. 11.5a, b), this can be done with 6–0 Vicryl sutures and can be left to dissolve spontaneously.
Fig. 11.5
(a) Child with lid margin tear. (b) Lid margin tear sutured with Vicryl and long ends taped over the lid with Steri-Strip
Lacerations Associated with Canthal Tendon Injuries
Trauma to the medial and lateral canthal tendon is usually the result of horizontal traction on the eyelid leading to avulsion at the weakest part either medial or lateral canthus. Laceration near medial canthus is associated with canalicular and lacrimal sac injury in most of the cases. Assess the integrity of medial and lateral canthal tendon by grasping the lid with a toothed forceps and tugging away from the injury while palpating the tendon insertion. The surgeon should assess whether the anterior or posterior limb is avulsed. Repair of the posterior limb is more critical to achieve proper lid positioning.
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