Akshay Gopinathan Nair
Akshay Gopinathan Nair received his medical degree from Maharashtra University of Health Sciences, India and completed his residency training in ophthalmology from Sankara Nethralaya in Chennai, India. Following this, he underwent fellowship training in ophthalmic plastic surgery, ocular oncology and facial aesthetics at L V Prasad Eye Institute, Hyderabad, India and New York Eye & Ear Infirmary of Mount Sinai, USA. Dr. Nair has over 50 peer-reviewed publications, 8 book chapters in ophthalmology. His areas of special interest are ocular surface and eyelid tumours, ophthalmic imaging and neuroimaging. Dr. Nair is a faculty member at Lokmanya Tilak Municipal Medical College, Mumbai, India and is also affiliated with Advanced Eye Hospital & Institute and Aditya Jyot Eye Hospital in Mumbai.
Bipasha Mukherjee
Dr. Bipasha Mukherjee is a fellow in Orbit & Oculoplasty from Aravind Eye Hospitals, India, and ICO fellow from University Hospital of Limoges, France, under Prof. Jean-Paul Adenis. She has undergone clinical observerships with stalwarts like Jack Rootman, Richard Collins, Geoff Rose, Mark Duffy, and Robert Goldberg.
She currently heads the department of Orbit, Oculoplasty, Aesthetic & Reconstructive services in Medical Research Foundation, Chennai. She has numerous presentations in national and international conferences and publications in peer-reviewed journals and text books. Her areas of interest include diseases of the orbit and adnexa including tumors, lacrimal surgery, socket reconstruction, traumatic lid and adnexal injuries, training residents and fellows, and photography.
Animal bite injuries to the face are seen in emergency rooms across the world. Mammalian bites account for nearly 10 % of patients who present with orofacial trauma. Animals commonly responsible for bites include dogs, cats, horses, rabbits, rats, and humans [1, 2]. Of these, dog bites constitute 60–80 % of all animal bite injuries and cat bites – 20–40 % [3]. Children are often the target of animal attacks, primarily due to their behavior, which may be perceived as provocative by animals and also their small stature, which makes them vulnerable and accessible. Facial injuries constitute nearly 10–15 % of all animal bite trauma, and children are involved in nearly half of them [2, 4]. It has been reported that children under the age of 4 years receive injuries to the head, face, and neck in 63 % of cases, whereas children who are over 4 years of age suffer extremity injuries 78 % of the time [5]. Since majority of animal bites are dog related and given the complexities of canine-related trauma, this chapter would focus largely on periocular dog bites. The principles of successfully managing periocular dog bites are thorough wound toilet, debridement, and subsequent reconstructive surgery. Concurrent immunization against rabies and adequate infection control too are equally important. Early management of complex periocular injuries usually guarantees satisfactory outcomes.
Types of Injuries
Anecdotal evidence suggests that dogs preferentially attack the central face. This often results in trauma to the nose and eyelids. In addition to trauma to the globe, dog bites can present with a spectrum of periocular injuries such as lid abrasions, canthal avulsions, eyelid lacerations, canalicular tears, and trauma to extraocular muscles (Fig. 6.1). Fractures are relatively uncommon with one study reporting six cases of facial fractures associated with dog bites and reviewing ten other previously reported cases in literature [6].
Fig. 6.1
A 2-year-old male child who gave a history of a dog bite while playing with his pet dog, showing the most common form of eyelid trauma following dog bite. There is a lower lid avulsion with obvious canalicular trauma
Treatment
It is important to obtain all relevant history to ascertain if the dog responsible for the bite was rabid or not, to check if the bite was provoked or unprovoked, to check if there were similar dog bites in the neighborhood on the same day or recent times involving the same dog.
The aims of treatment of such injuries can be broadly enlisted as:
Adequate wound toilet to prevent wound infection
Rabies prophylaxis
Exploration and surgical reconstruction of normal anatomy with maximum restoration of function
Primary Care
Facial bites are classified as category III dog bites which indicate single or multiple transdermal bites or scratches. This warrants both local treatment of the wound and complete postexposure prophylaxis measures including immunoglobulin and vaccination.
The initial management of any periocular animal bite-related trauma is thorough cleaning and debridement. The wound can be washed with soap and water, although ideally, a virucidal agent like povidone-iodine, if available, should be used. If required, this may be done under general anesthesia especially in smaller children. It is extremely important to debride the wound site of all devitalized tissue, remove all foreign bodies, and expose the surrounding healthy tissue [7]. The Center for Disease Control (CDC) guidelines recommend that 20 IU/kg of human rabies immunoglobulin (RIG) should be injected around the wound site after cleaning. Furthermore, any remaining RIG can be administered intramuscularly at an anatomical site distant from vaccine administration. Of particular importance is to ensure that while injecting RIG, it should not be administered in the same syringe as the vaccine. This is because there is a possibility that RIG might partially suppress the active production of antibody. Following this, human diploid cell rabies vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL intramuscularly, one each on days 0, 3, 7, and 14 should be administered [8]. Tetanus vaccine may also be given simultaneously after checking the patient’s vaccination status.
Posttraumatic stress disorder following dog bites is a known phenomenon, especially in children [9]. Appropriate counseling should be provided in such cases.
Surgical Management
Prior to any surgical treatment, it is a worthwhile clinical practice to routinely photograph the wound before and after cleaning [10]. Look for any associated trauma such as occult globe rupture, trauma to the canaliculi, levator muscle, and extraocular muscles and also for bony fractures [11]. There has been a controversy regarding primary closure of dog bite wounds. However, Rui-feng and colleagues reported that facial laceration of dog bite wounds should be primary closed immediately after formal and thorough debridement. Primary closure shortens the healing time of the wounds without increasing the rate of infection [7]. The eyelids are so well vascularized that the majority of these injuries may be primarily closed with superficial sutures (see Chap. 11).
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