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 Table of Contents  
PG CORNER
Year : 2018  |  Volume : 30  |  Issue : 3  |  Page : 222-227

Management of eyelid lacerations


Oculoplasty and Neuroophthalmology Fellow, Little Flower Hospital, Angamaly, Kerala, India

Date of Web Publication17-Dec-2018

Correspondence Address:
Rita Mary Tomy
The Retreat, CN 203, Angamaly - 683 572, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_83_18

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  Abstract 

Eyelid lacerations form a major bulk of the ocular trauma that we see in our casualty. These are managed differently depending on the depth, width, and location of the injury. Repairing of eyelid injuries requires good anatomic knowledge and meticulous approach. This article gives a brief overview of the practical aspects in managing an eyelid laceration.

Keywords: Canalicular tear, eyelid laceration, margin tear


How to cite this article:
Tomy RM. Management of eyelid lacerations. Kerala J Ophthalmol 2018;30:222-7

How to cite this URL:
Tomy RM. Management of eyelid lacerations. Kerala J Ophthalmol [serial online] 2018 [cited 2019 May 25];30:222-7. Available from: http://www.kjophthal.com/text.asp?2018/30/3/222/247596


  Introduction Top


Eyelids are protective curtains in front of eyes which give shape and beauty to the face. Any defect or injury to eyelids due to trauma or surgical excision needs to be meticulously repaired for the best possible cosmetic outcome. Road traffic accidents, blasts, and falls are the major causes resulting in injuries to eyelids. Traumatic laceration to the eyelid requires a thoughtful, well-planned approach in order to provide the best outcome and reduce the chances of postoperative complications.


  Surgical Anatomy Top


Eyelid margin

Eyelid margin has a slightly rounded anterior edge and sharp posterior edge. Anatomical structures in eyelid margin are shown in [Figure 1].
Figure 1: Eyelid margin anatomy (illustration by Christine Gralapp)

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Gray line lies anterior to  Meibomian gland More Details openings and represents an avascular plane between the orbicularis and the tarsal plate. It is the plane along which the lid can be spilt into two halves.

Functional anatomy of the lid can be simplified by dividing lid into two parts along gray line.

  • Anterior lamella – eyelid skin and orbicularis muscle
  • Posterior lamella – conjunctiva and tarsal plate.


Medial canthus and lateral canthus

Fibrous extension from the tarsal plate forms the canthal tendons [Figure 2].[1] Canthal tendons maintain horizontal pull on the lids to maintain proper lid apposition.
Figure 2: Eyelids, deep dissection of structural elements

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  Preoperative Evaluation Top


First and foremost is a detailed history regarding the time, course, and circumstances of injury.

Rule out occult injuries

For full-thickness upper eyelid injuries, never forget to check for globe perforations. Globe injuries should be attended before lid injuries. Eyelid trauma can be associated with hyphema, angle recession, or retinal detachment. Detailed ocular examination includes visual acuity, ocular movements, intraocular pressure, pupillary reactions, and posterior segment examination.

Clear watery discharge from one nostril indicates cerebrospinal fluid rhinorrhea and is a red alert sign to look for anterior skull base fractures.

Wound inspection, cleaning, and documentation

We save all eyelid tissues, as high vascularity often allows for viable re-approximation of partially avulsed ocular adnexal tissue [Figure 3]. We photograph all preoperative injuries and immediate postoperative results.
Figure 3: Avulsed eyelid laceration

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A broad-spectrum prophylactic antibiotic cover is preferred (such as amoxicillin-clavulanate or clindamycin for the penicillin-allergic). Tetanus prophylaxis may also be required.

Tear outflow system

Blunt injury to the medial eyelid with resultant eyelid laceration almost always tears the canaliculus. Telecanthus is noted in case of outfracture of the lacrimal bone or laceration of the medial canthal tendon. In eyelid lacerations medial to the puncta, the canaliculi should be probed to assess integrity [Figure 4]. We have found that most eyelid injuries can wait 24–48 h for soft-tissue swelling to improve.
Figure 4: Probing to assess canalicular integrity in medial tears

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Anesthesia

Most of our cases are operated under local anesthesia. Facial block can be supplemented. We prefer general anesthesia or deep monitored anesthesia care for complex lacerations involving the canaliculi, underlying bone fractures, and when operating on young children.


  Principles of Lid Repair Top


  1. Wounds should be copiously irrigated and explored, with the removal of any foreign material after local anesthesia
  2. Reconstruction should be done in layers as per correct anatomical orientation
  3. Wounds should not be extended to explore structures unless the exploration is for suspected foreign body
  4. The orbital septum if damaged should never be repaired, as this may result in compromised eyelid excursion and even lagophthalmos. We should avoid suture incorporation of the septum during repair
  5. The presence of orbital fat raises the risk of deeper injury and foreign bodies
  6. In brow lacerations, eyebrows should never be shaved off as orientation of the brow hair will help us in correct approximation [Figure 5]
  7. Anterior lamellar defects not involving lid margin should be repaired by primary closure.[2] If required, undermining of the surrounding skin was done to mobilize skin for adequate closure. Interrupted sutures with 6-0 vicryl may allow for hematoma egress or infection drainage
  8. We should repair deep tissues first. Posterior lamella (tarsus, retractors, and conjunctiva) repair is dependent on the extent of injury. Conjunctival lacerations of 5 mm or less often do not need to be repaired unless there are apposing lacerations of the bulbar and palpebral surface that may adhere forming a symblepharon. We use 8-0 vicryl suture for larger conjunctival lacerations
  9. Primary repair of the levator aponeurosis is done by repositioning it to the upper half of the tarsus with permanent 6-0 or 7-0 suture material.
Figure 5: Brow laceration pre- and postrepair

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Full-thickness lid margin lacerations, canalicular tears, canthal injuries, and lacerations with tissue loss are entities which should be meticulously tackled using specialized techniques.


  Eye Lid Margin Repair Top


  • The wound should be carefully inspected to identify tarsus and lid margin landmarks such as gray line, anterior lash line, and posterior margin
  • Repair should be carried out preferably under operating microscope.



  “Three-Suture Technique” Top


  1. Vertical mattress suture along the gray line using 5-0 silk suture passed just like the traditional vertical (“far-far then near-near”) mattress in line with the meibomian orifices [Figure 6]. A good apposition with slight margin eversion should be the goal[3]


  2. The tarsus is next closed with interrupted, partial-thickness 6-0 vicryl sutures

  3. Simple suture passed along the anterior lash line
  4. Simple suture in the posterior mucocutaneous junction.
Figure 6: Vertical mattress suture along the gray line

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All suture ends are left long. The anterior lamella of the eyelid is closed next, with interrupted sutures using 5-0 silk. The long end of the margin sutures is buried into the knots of these skin sutures to prevent the suture ends from abrading the cornea [Figure 7]a and [Figure 7]b. Sutures are removed after 2 weeks [Figure 7]c. All tarsal irregularities at the wound edges should be trimmed to allow good tarsal-to-tarsal approximation which prevents tarsal buckling and postoperative notching of lid margin.
Figure 7: (a) Eyelid marginal tear. (b) Tear repaired by three suture technique. (c) After suture removal at 2 weeks

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  Repair of Canthal Injuries Top


The rounded configuration of the medial canthus and/or the acute angle of the lateral canthus can be distorted or lost in canthal injuries [Figure 8]. The integrity of the canthal tendon is tested by grasping the lid with toothed forceps and pulling toward the limbus.[3]
Figure 8: Lid laceration with medial canthal tendon injury

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The avulsed lateral canthal tendon should be sutured or wired at the tubercle so that it is 1–2 mm higher than the medial canthus.

The posterior limb of the medial canthal tendon is primarily responsible for the medial canthal configuration. The ruptured tendon can be sutured to the posterior lacrimal crest or as posterior as possible taking special care not to injure the lacrimal sac. The anterior head of the medial canthal tendon can be sutured directly to its anterior lacrimal crest insertion.


  Eyelid Injuries With Tissue Loss Top


These are very rare.

Full-thickness eyelid defects with tissue loss are classified depending on the horizontal extent of defect into[4]

  1. Small defects (<1/3)
  2. Medium defects (1/3–1/2)
  3. Large defects (>1/2).


Repair of small defects (<1/3 of horizontal length)

Direct closure

This is possible because of increased eyelid laxity, especially in older patients.

Lateral canthotomy and cantholysis

This provides additional horizontal lengthening in lateral canthotomy, and horizontal limb of Y-shaped lateral canthal ligament is incised. For cantholysis, inferior or superior crus of lateral canthal tendon is incised.

Repair of moderate defects (up to 1/2 of horizontal length)

Tenzel semicircular flap

It can be used for both upper lid and lower lid defects where some tarsus remains on either side of the defect. A high arched semicircular flap of the skin and orbicularis muscle is rotated from lateral canthus after lateral cantholysis. The flap dimensions are 22 mm × 18 mm (V × H). For upper lid defects, the semicircle extends inferiorly, and for lower lid, the semicircle extends superiorly. After undermining of the tissue, the lid is pulled medially and direct lateral canthus is created [Figure 9].
Figure 9: Tenzel semicircular flap

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Repair of large defects (>½ of horizontal length)

Cutler-Beard bridge technique

Originally described for reconstruction of the upper lid, this technique can be used for reconstruction of the lower lid defect also, a procedure known as reverse Cutler-Beard.

Cutler-Beard procedure is done in two stages [Figure 10].
Figure 10: Cutler-Beard procedure Stage 1: (a) Full thicknes upperlid defect.(b) A three-sided inverted U-shaped incision is marked on the lower eyelid, about 5 mm below lid margin. (c) By a full-thickness incision, the lower lid flap is pulled under the bridge of lower lid and sutured in layers to the upper lid defect. Since this flap is devoid of the tarsus, autogenous cartilage from the ear can be used. Stage 2: (d) Separation of the flap at 6 weeks to 3 months. After cutting the flap, lid margin of newly formed upper eyelid is sutured with conjunctiva covering the free margin.

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Hughes tarsoconjunctival flap technique

It is partial-thickness posterior lamellar flap harvested from upper lid to cover lower lid defects [Figure 11].
Figure 11: (a) Upper lid is everted, incision is made through tarsus 4 mm above lid margin, and flap is mobilized. (b) Flap is sutured with lower lid tarsus to create posterior lamella. Sufficient skin to cover the anterior surface of the flap is obtained by advancing a myocutaneous flap from surrounding skin

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Mustarde cheek rotation flap

It is reserved for the reconstruction of very extensive lower eyelid defects usually involving more than 75% of the eyelid. The side of the triangle nearest the nose should be practically vertical. The advantage of this procedure is that it is a one-stage, complete lower lid reconstruction [Figure 12].
Figure 12: Mustarde cheek rotation flap. (a) A large myocutaneous cheek flap is dissected and used in conjunction with an adequate mucosal lining posteriorly. (b) A deep inverted triangle must be excised below the defect. The side of the triangle nearest the nose should be practically vertical. (c) Adequate rotation and suturing of the flapto cover the defect.

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  Repair of Canalicular Laceration Top


Canalicular injury should be suspected in all lacerations which are medial to the punctum [Figure 13]. All canalicular lacerations should be repaired whether upper or lower under operating microscope. Identification and retrieval of the proximal end of canaliculus is the most difficult step. Methods used are:
Figure 13: Parts of Mini-Monoka monocanalicular stent

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  • Examination under high magnification
  • Gentle irrigation of fluid or air injection through uninjured canalicular system
  • Dyes such as methylene blue or diluted fluorescein can also be used.


If proximal end is crushed and cannot be retrieved, eyelid should be closed without further manipulation.


  Materials Used for Canalicular Stenting Top


  1. Crawford bicanalicular stents
  2. Mini-Monoka monocanalicular stents
  3. Angiocath I/V cannula 22 gauge.


Mini-Monoka monocanalicular stents are used in our hospital with excellent postoperative results [Figure 13] and [Figure 14]. It has a self-retaining cap which sits at the punctum giving it excellent stability and avoids extrusion or displacement of stent. It also has the advantage of not disturbing the uninjured canaliculus. Only disadvantage is the high cost of stent.
Figure 14: (a) Medial lower eyelid laceration with canalicular tear. (b) Canalicular tear repaired with Mini-Monoka stent (blue arrow)

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  Follow-Up Top


Sutures are generally removed as follows:

  • -Low-to-moderate tension eyelid wounds at 5–7 days
  • -Marginal sutures at 2 weeks
  • -Mini-Monoka removal is done at 3 months.


At all follow-up visits, meticulous chart documentation is critical, and supplemental photographic documentation is desirable.


  Complications Top


  1. Lid margin notching
  2. Lagophthalmos
  3. Hypertrophic scars
  4. Infections
  5. Tearing
  6. Traumatic ptosis.



  Conclusion Top


Repairing of eyelid injuries is an art which requires good anatomic knowledge and meticulous approach. Gentle tissue handling and proper alignment should be done. The aim should be to achieve the best possible functional and cosmetic outcome. Always bear in mind that “Primary repair is the best repair.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia: Saunders 1994:126.  Back to cited text no. 1
    
2.
Vichare N. Management of lid lacerations ocular trauma. Delhi Ophthalmol Soc Times 2015;20:33-8.  Back to cited text no. 2
    
3.
Nelson CC. Management of eyelid trauma. Aust N Z J Ophthalmol 1991;19:357-63.  Back to cited text no. 3
    
4.
Carroll RP. Management of eyelid trauma. In: Hornblass A, editor. Oculoplastic Orbital, and Reconstructive Surgery. Vol. 45. Baltimore: Williams & Wilkins; 1988. p. 409-14.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]



 

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  In this article
Abstract
Introduction
Surgical Anatomy
Preoperative Eva...
Principles of Li...
Eye Lid Margin R...
“Three-Sut...
Repair of Cantha...
Eyelid Injuries ...
Repair of Canali...
Materials Used f...
Follow-Up
Complications
Conclusion
References
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