Eyelid Laceration Treatment & Management

Infections, including periorbital necrotizing fasciitis ^[6] (streptococcal gangrene), occurring after upper eyelid lacerations have been described. Therefore, clinicians must maintain a high index of suspicion for any accompanying infections in patients with eyelid trauma.

Tetanus

If the patient has never been immunized, administer 250 U of intramuscular human tetanus immune globulin.

Administer intramuscular or subcutaneous tetanus toxoid (0.5 mL), if the patient did not have tetanus immunization in the preceding 10 years.

For unclean wounds or puncture wounds, administer tetanus toxoid for patients who have not had it within 5 years.

Animal bite wounds

Oral flora, such as Streptococcus, Pasteurella, and Bacteroides species, may infect bite wound lacerations. Capnocytophaga canimorsus (dysgonic fermenter type 2) infection is a potentially life-threatening virulent infection that can result after dog bites, especially in splenectomized patients. ^[7]

Wound debridement and copious irrigation (eg, bacitracin) are important for all bite wounds. Useful intravenous antibiotics include penicillin G, cefazolin, and ampicillin sulbactam. Antibiotic selection and dose should be confirmed with the hospital pharmacy and an infectious disease specialist.

In bite wounds that are older than 24 hours, consider allowing the wounds to granulate, if there is adequate corneal protection.

Rabies

If the bite was from a wild animal, administer rabies prophylaxis if brain tissue from the offending animal cannot be examined.

If a domestic pet was the culprit, check the rabies immunization status and quarantine the animal for 10 days, preferably with a veterinarian.

If a patient has a ruptured globe and a lid laceration, first repair the globe rupture. If there is an extensive lid laceration in this setting, lid speculums may not work. Traction sutures (eg, 4-0 silk) on the lacerated lid segments will facilitate globe repair.

Although repair of lid lacerations can be delayed, early repair may allow better corneal protection, less tissue edema, and better wound decontamination. If the lid repair must be delayed in favor of more life-threatening injuries, perform the following:

• Ensure adequate corneal lubrication.

• Clean the wound as much as possible.

• Keep the wound moist. A plastic occlusive dressing, like that used to cover intravenous sites, can be lightly applied over antibiotic dressing to help protect the cornea.

• Consider systemic antibiotic coverage.

Try to save or retrieve all lid tissue. The ocular adnexa has a good blood supply, and even ischemic-appearing tissue often heals.

Most adult lid lacerations can be repaired in the emergency department under local anesthesia. Good lighting and loupe magnification will aid wound exploration and repair.

• Patients may be more comfortable in a slight reverse Trendelenburg position on a stretcher in the emergency department.

• In uncooperative, inebriated patients, it may be better to delay the repair until the patient is sober.

• Other uncooperative patients or children may require general anesthesia.

Administering topical anesthetic drops and topical lidocaine gel followed by placing a corneal protector, when possible, is one preferred method. The corneal protector can be inserted with sterile gloves prior to anesthetic injection. Injecting anesthetic with epinephrine prior to wound cleansing affords better patient cooperation and wound visualization.

• Eyelid necrosis following lidocaine with epinephrine injection is rare but has been described. Epinephrine may cause prolonged vasoconstriction and is a relative contraindication in patients with sickle cell disease, arteritis, Raynaud phenomenon, and severe microvascular disease. ^[8]

• Supplemental regional blocks may be helpful in pain control. For example, an infraorbital nerve block may be given to patients with lower lid lacerations.

After adequate anesthesia, the next objective is wound cleansing and decontamination.

• Stevenson has described hydraulic irrigation with a 19-gauge needle on a 20-mL syringe. ^[9] The plastic hub of an intravenous catheter can be used in place of a needle.

• Excessive tissue irrigation can cause lid edema. Wound irrigation with normal saline or bacitracin soak with a 10 mL-syringe sans needle or a bulb syringe is preferred.

After preparing and draping, carefully inspect wounds for foreign bodies.

• If particulate matter is embedded in the wound, cleansing the skin with a surgical scrub brush will help prevent a traumatic tattoo.

• Debriding the tissue with a chalazion curette is helpful. The curette can also be used to palpate for foreign bodies.

• Orbicularis retraction may give the appearance that some of the lid tissue is missing when it actually is not.

Injuries that involve the medial canthus may involve the canaliculi. It is usually easiest to repair canalicular injuries prior to lid margin and canthal injuries. Instilling viscoelastic in the intact canaliculus may help in identification of the lacerated canaliculus. The medial cut end of the lower canaliculus may be more easily visualized if an upper punctal probe is pushed towards the lower lid lacerated skin margin. ^[10] Alternatively, a round-tipped, eyed pigtail probe, placed through the intact canaliculus, can help in the identification and repair of the lacerated canaliculus, if the patient has a common canaliculus. ^[11]

• Monocanalicular stents (eg, Mini Monoka) are becoming increasingly popular. Bicanalicular stents, such as Crawford/Ritleng tubes, are commonly used and readily available.

• Canalicular repair is best accomplished with the operating microscope. After the canalicular system has been intubated with a stent, 3 sutures can be placed around the canaliculus. Some advocate 10-0 nylon sutures for canalicular repair. Because they are easy to use and less prone to tearing, 8-0 polyglactin sutures also are preferred. If a bicanalicular stent is employed, tighten the bicanalicular stent prior to tying the sutures to decrease suture tension.

Medial canthal avulsions are usually surgically repaired. However, the use of bicanalicular stenting alone, without posterior lacrimal crest fixation, has been described. ^[12] Lacerations of the deep head of the medial canthal ligament cause telecanthus (unlike lacerations of the superficial head of the canthal ligament). Medial canthal degloving injuries often present with a vertically oriented laceration traversing the medial canthus, with telecanthus, ptosis, and nasolacrimal injury. Repair should be performed in a staged fashion, first addressing telecanthus and lacrimal system. Ptosis surgery is usually done at a later stage. ^[13]

• Posterior tendon repair should precede lacrimal repair, but bicanalicular intubation is easier to perform prior to definitive posterior tendon repair.

• In some instances, the deep head of the tendon can be reattached to the posterior lacrimal crest or medial orbit with a microscrew or plating system. If not possible, transnasal wiring may be required.

• Lid margin lacerations are usually repaired prior to extramarginal lacerations to allow for better anatomic realignment. The author prefers to use a single vertical mattress ^[14] stitch of 6-0 silk or 6-0 polyglactin to realign the lid margin. Traditionally, however, 3 marginal sutures of 6-0 caliber are used to realign the lid margin; this technique is described below.

• The first suture passes through the plane of meibomian orifices with additional sutures placed anteriorly and posteriorly.

• The suture ends are kept long and secured on the cutaneous antemarginal surface.

• The lid margin sutures should slightly evert the lid margin to prevent lid notching. A vertical mattress suture may facilitate eversion of the lid margins. ^[14]

• If the antemarginal tarsus is lacerated, 2 or 3 6-0 polyglactin sutures can be placed through one-half to three-quarters thickness tarsus with the knot ends directed away from the cornea.

• The orbicularis can be closed with 6-0 polyglactin suture.

• Skin can be closed with 6-0 fast-absorbing gut suture or 6-0 nylon. The ends of the lid margin suture can be secured in 1 or preferably 2 cutaneous extramarginal sutures.

• If it is suspected that the patient will not comply with follow-up care, use absorbable sutures for the entire lid repair.

• In children who may not cooperate for later stitch removal, 6-0 fast-absorbing gut suture can be used if the laceration does not involve the lid margin. Keep in mind that if the child frequently rubs the eyes or sleeps prone, the fast-absorbing gut sutures may prematurely come loose.

• Cutaneous sutures are removed on Days 5-7, and Steri-Strips can be applied, if necessary. Removal of lid margin sutures at day 11-14 is a preferred method.

• Extramarginal lid lacerations often follow relaxed skin tension lines; they heal well, if tissues are properly reapposed. As with all lid repairs, minimize vertical tension. In large upper lid extramarginal lacerations, using the eyebrow hairs as a landmark may allow better anatomic tissue realignment. If suturing dark eyebrow hairs, using a stitch that is not black aids in visualization.

• Small lacerations that parallel the relaxed skin tension lines may sometimes be closed with Steri-Strips. Dermabond (2-octyl cyanoacrylate), a glue, has been described for skin closure; however, care must be taken to ensure that this glue does not adhere to the lids or touch the cornea. Glue should not be used for jagged, stellate, deep, contaminated, bite, or crush wounds.

• In closing deep lacerations, avoid attaching the muscle, skin, or levator to the orbital septum; otherwise, lid lag occurs. Closure in layers and eversion of skin edges provides the best cosmesis.

Dehiscence of the lateral canthal ligament is not uncommon and may not be apparent when the lid is edematous and the patient is supine. Repair the lateral canthal ligament at the time of lid laceration, unless marked proptosis is present.

Posttraumatic upper lid ptosis

In patients with marked lid edema, judge the severity of posttraumatic ptosis after the edema has resolved.

When judging lid height, instill topical anesthetic in the eye to exclude the possibility of ocular irritation as a cause of lid closure. If the patient is also being dilated, remember that phenylephrine drops may alter the lid height.

One preferred method is to wait up to 6 months for spontaneous improvement of traumatic ptosis, unless there is the potential for amblyopia or the patient is monocular.

Postoperative care

Ensure adequate corneal lubrication, if required.

As with other eyelid surgeries, head elevation, cold compress, and antibiotic ointment are advisable.

Antibiotic ointments, including erythromycin or antibiotic steroid preparations, such as Maxitrol (neomycin, polymyxin, bacitracin, dexamethasone), used 3-4 times daily, are recommended.

Steroid ointment should be used with caution if underlying infection or corneal abrasion is suspected.

Patching is usually not preferred, so that visual acuity can be checked and undue pressure on the globe avoided. Apply a transparent eye shield if either of the following is suspected: the patient will rub the eyelids when awakening from the anesthetic, or the patient will rub the eyes when sleeping.

Although pain management should be assessed on an individual basis, most patients do not require analgesia that is stronger than acetaminophen.

Occasionally, corneal ulceration may result from corneal exposure or an exposed suture that rubs against the cornea. Tell patients to return if they have persistent ocular discomfort or unexplained anterior segment erythema.

The eyelids have an excellent vascular supply. In the rare instance of postoperative wound necrosis, hyperbaric oxygen may be useful. ^[15]

Lid notching and epiphora may occur.

Provide follow-up care, especially if the lacrimal system is involved to detect epiphora. On follow-up examination, check for lid notching.