Introduction
Background
Lacerations of the canalicular system often occur in the setting of trauma.1,2 The canaliculi are the mucosal ducts through which tears drain from the eye.3 The canalicular portion of the tear drainage system is in the medial aspect of the lid. The lacrimal drainage apparatus consists of the puncta on the upper lid and the lower lid, the canaliculi, the common canaliculus, the lacrimal sac, and the nasolacrimal duct.
Each eyelid margin can be divided into the larger palpebral portion (consisting of skin, orbicularis muscle, insertion of lid retractors, tarsal plate, and conjunctiva) and the smaller lacrimal portion (consisting of skin, orbicularis, canaliculi, and conjunctiva).4 The palpebral potion of the lid is lined with lashes; posterior to the lashes are the openings of the meibomian glands of the tarsal plate. The palpebral margin assumes a flat contour. The lacrimal portion of the lid is round and without lashes. Injuries to the canalicular portion of the tear drainage system can occur as isolated injuries or as one component of more extensive injuries, including multiple marginal lid lacerations, orbital fractures, and globe injuries.1
Pathophysiology
Lacerations of the canalicular system result from direct or indirect trauma.5,6 Direct trauma includes severing the lacrimal portion of the lid with objects, such as glass, coat hangers, knives, dog bites, cat claws, fingernails, or other sharp objects. Indirect trauma results from blunt injury to the ocular adnexa from such mechanisms as blows to the face, blunt weapons, or falls onto blunt objects.
Because of its superficial location in the medial lid, the canalicular system is vulnerable to trauma. The anatomy of the system includes the 2-mm vertical portion, which drains the puncta, and the 8-mm horizontal limb, which lies in the lacrimal portion of the lid, approximately 2 mm from the lid margin. The medial extent of the canaliculus interrupts the posterior arm of the medial canthal ligament. This ligament often is disrupted from the trauma and must be repaired to reestablish anatomic position and lid function.
Frequency
United States
Canalicular lacerations are the most frequent cause of injury to the lacrimal system. The inferior canaliculus is involved in more than 50-75% of cases. The horizontal lower limb is the most frequently involved site. In 2002, there were approximately 1.97 million visits to emergency departments for facial lacerations. Lacerations to the canalicular system account for a very small percentage of these facial lacerations. A survey of surgeons in the United Kingdom found that 83% of 92 surgeons repaired fewer than 5-10 canalicular lacerations per year.
International
A 2-year study of patients with eyelid injuries in Munich, Germany, found that 16% of eyelid lacerations involved the canalicular system.7 A 2006 survey of United Kingdom ophthalmologists showed that management of canalicular lacerations varies widely in the United Kingdom.8
Mortality/Morbidity
If the canalicular system is not repaired initially, tearing can result from the disruption of the lacrimal anatomy, and the medial canthal area can have an abnormal appearance. Studies have demonstrated that both the inferior and the superior lacrimal drainage system can be instrumental in proper function of the tear drainage system. Primary repair can restore both lid function and position. Once the microscopic lacrimal system is scarred, it cannot be functionally repaired.
Race
Race has not been reported to be a factor in trauma to the canalicular system.
Sex
Males are more frequently the victims of trauma to the lacrimal system than females.
Age
Canalicular lacerations are most common in young adults. Canalicular lacerations in toddlers frequently result from dog bites. The mean age range is reportedly 18-30 years.
Clinical
History
The mechanism of injury must be elicited during the history.6 Delineating the mechanism of injury helps to establish the extent of injury, the possibility of associated ocular damage, the degree of contamination, and the risk for retained foreign bodies.
- Objects projecting from the wound may indicate intracranial injury. Until imaging studies are obtained, projecting objects should not be extracted.
- Ground soil contamination may raise the need to cover for Bacillus cereus.
- Dog bite injuries need immediate decontamination.
- Documentation of the cause of injury, including whether the accident was work related, can be important medicolegal information.
Physical
In the setting of acute trauma, attention to life-threatening and then visual-threatening injuries, particularly an open globe, must take precedence over examination or repair of any adnexal injury.
- A complete ophthalmic examination must be performed, including visual acuity, pupil reaction (with specific mention of whether a relative afferent pupillary defect is present), visual fields, extraocular movements, intraocular pressure, external examination, slit lamp examination, and dilated examination of the optic nerves and posterior pole. Injuries of the lacrimal system can occur in the setting of major head trauma, in which case, dilation of the pupils may not be permissible from a neurologic standpoint.
- Any lid laceration medial to the pupil should be considered to involve the canalicular system until proven otherwise. To check for disruption of the system, the puncta can be dilated, followed by insertion of a Bowman probe. Another method of confirming a canalicular laceration includes irrigating substances, such as fluorescein stained balanced saline solution, through the system with visualization of the dye in the wound.
- Examination of the orbit for any associated injuries (eg, orbital fractures) must be performed. Fractures of the maxillary bone in the area of the nasolacrimal duct can cause difficulty in silicone intubation through the nasolacrimal duct.
Causes
Causes of canalicular lacerations include assaults, falls and collisions, sharp trauma (eg, knives, coat hangers, fingernails, glass), motor vehicle accidents, dog bites, cat scratches, and sports trauma. Sixty-six percent of all patients with a dog bite – related injury had involvement of the canaliculi in a 10-year study of patients presenting to the Massachusetts Eye and Ear Infirmary.9
The photographs below show a patient with a canalicular injury from a dog bite and postoperative result.
Toddler who sustained a dog bite injury with isolated canalicular laceration of the left lower lid.
Postoperative (1.5 y after injury) appearance of toddler who sustained a dog bite injury with isolated canalicular laceration of the left lower lid. This photo demonstrates normal anatomy and function of the eyelid.
The photographs below show a canalicular injury sustained from a fingernail and postoperative result.
Canalicular system intubated with 6-0 Prolene suture prior to passing a segment of Crawford stent in a patient who sustained superior canalicular laceration from a fingernail injury while playing basketball.
Postoperative appearance of a patient who sustained superior canalicular laceration from a fingernail injury while playing basketball.
Canalicular laceration incurred during a motor vehicle accident is shown in the photographs below.
Canalicular laceration in the setting of a more extensive medial canthal injury in a woman involved in a motor vehicle accident.
Postoperative appearance of the patient in the photo above who sustained canalicular laceration following a motor vehicle accident.
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References
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Canavan YM, Archer DB. Long-term review of injuries to the lacrimal drainage apparatus. Trans Ophthalmol Soc U K. Apr 1979;99(1):201-4. [Medline].
Linberg J. Surgical anatomy of the lacrimal system. In: Linberg J, ed. Lacrimal Surgery. New York: Churchill Livingstone; 1988:1-18.
Dutton J. Atlas of Clinical and Surgical Orbital Anatomy. Philadelphia: WB Saunders; 1994:240.
Wulc AE, Arterberry JF. The pathogenesis of canalicular laceration. Ophthalmology. Aug 1991;98(8):1243-9. [Medline].
Jordan DR, Ziai S, Gilberg SM, Mawn LA. Pathogenesis of canalicular lacerations. Ophthal Plast Reconstr Surg. Sep-Oct 2008;24(5):394-8. [Medline].
Herzum H, Holle P, Hintschich C. [Eyelid injuries: epidemiological aspects]. Ophthalmologe. Nov 2001;98(11):1079-82. [Medline].
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Gonnering R. Periorbital animal bites. In: Linberg J, ed. Oculoplastic and Orbital Emergencies. Prentice Hall; 1990:215-228.
Liang T, Zhao KX, Zhang LY. A clinical application of laser direction in anastomosis for inferior canalicular laceration. Chin J Traumatol. Feb 2006;9(1):34-7. [Medline].
Jordan DR, Gilberg S, Mawn LA. The round-tipped, eyed pigtail probe for canalicular intubation: a review of 228 patients. Ophthal Plast Reconstr Surg. May-Jun 2008;24(3):176-80. [Medline].
Hawes MJ, Segrest DR. Effectiveness of bicanalicular silicone intubation in the repair of canalicular lacerations. Ophthal Plast Reconstr Surg. 1985;1(3):185-90. [Medline].
Reifler DM. Management of canalicular laceration. Surv Ophthalmol. Sep-Oct 1991;36(2):113-32. [Medline].
Conlon MR, Smith KD, Cadera W. An animal model studying reconstruction techniques and histopathological changes in repair of canalicular lacerations. Can J Ophthalmol. Feb 1994;29(1):3-8. [Medline].
Jordan DR, Nerad JA, Tse DT. The pigtail probe, revisited. Ophthalmology. Apr 1990;97(4):512-9. [Medline].
Saunders DH, Shannon GM, Flanagan JC. The effectiveness of the pigtail probe method of repairing canalicular lacerations. Ophthalmic Surg. Jun 1978;9(3):33-40. [Medline].
Kersten RC, Kulwin DR. "One-stitch" canalicular repair. A simplified approach for repair of canalicular laceration. Ophthalmology. May 1996;103(5):785-9. [Medline].
Further Reading
Keywords
canalicular laceration, canalicular system, canaliculi, tear drainage system, lacrimal drainage apparatus, lacrimal system, lacrimal sac, nasolacrimal duct, mucosal ducts, tear ducts
