Eyelid Burns

From EyeWiki


General Pathology

Ocular involvement occurs between 7.5% and 27% of patients admitted to burn units. The loss of an eye primarily from a thermal injury is rare due to a significant number of protective mechanisms such as the blink reflex, Bell phenomenon, and protective movements of the head and arms to avoid the source of a burn.

The most common causes of burn injury are fire/flame (46%) and scald (32%), with scald burns being a particular problem in children.

Pathophysiology

Burn injury results in the release of multiple inflammatory mediators that result in vasodilatation, pain, and edema.

The depth of burn depends on the intensity of heat exposure, the duration of exposure, and the thickness of epidermis and dermis. Eyelid skin is thin that leads to deeper burns than a similar exposure to skin elsewhere.

The three zones of a burn were described by Jackson in 1947.

Zone of coagulation—This occurs at the point of maximum damage. In this zone there is irreversible tissue loss due to coagulation of the constituent proteins. Zone of stasis—The surrounding zone of stasis is characterised by decreased tissue perfusion. The tissue in this zone is potentially salvageable, thus the main goal of burn resuscitation is to increase tissue perfusion here and prevent any damage becoming irreversible. Additional insults, such as prolonged hypotension, infection, or edema, can convert this zone into an area of complete tissue loss. Zone of hyperemia—In this outermost zone tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.

Diagnosis

Eyelid burns are classified depending on how deep and severe they penetrate the skin's surface.

Classification

Epidermal burns (first-degree burns)

This corresponds to the zone of hyperemia in Jackson’s model. Severe sunburn is the most common first-degree burn. By definition, this affects only the epidermis, and blistering is not common. Pain is due to local vasodilator prostaglandins, and healing is usually complete within a week.

Partial-thickness burns (second-degree burns)

Partial-thickness burns involve the dermis and epidermis. This corresponds to the zone of stasis in Jackson’s model. It is commonly divided into superficial and deep dermal injury.

  1. SUPERFICIAL PARTIAL-THICKNESS BURNS
    • Injury to the epidermis and superficial papillary dermis results in thin-walled, fluid-filled blisters with a moist red base. The exposure of superficial nerves makes these injuries painful. A burn of this depth heals within 2 weeks by regeneration of epidermisrom keratinocytes within sweat glands and hair follicles with minimal scarring.
  2. DEEP PARTIAL-THICKNESS BURNS
    • These burns have a pale white or mottled base beneath the blisters. The healing takes three or more weeks, and is accompanied by scarring and contraction. These injuries are of concern in the eyelid region, often necessitating early surgery for contraction and eyelid retraction.

Full-thickness burns (third-degree burns)

these destroy epidermis, dermis, and all regenerative elements and correspond to the zone of coagulation in jackson’s burn wound model. the skin is dry, leathery, and as a result of heat coagulation of dermal blood vessels, the affected tissue is avascular and white. such burns are typically painless due to loss of sensation in the involved area. healing only occurs from the edges and is associated with significant contraction. early excision of affected tissue and skin grafting is almost always required to resurface the burnt area and prevent secondary corneal complications.

Deep (fourth-degree burns)

These are full-thickness burns with destruction of the underlying muscle, bone and vital structures. such burns require extensive and complex management and often result in severe contracture and prolonged disability.

Based on these definitions and the likelihood of surgery, eyelid burns may be classified as minimal, moderate, or major. minimal burns describe superficial partial-thickness burns that usually heal without the need for surgery. moderate burns refer to deeper partial-thickness burns that are delayed in healing but may not require surgery. major eyelid burns are deep-partial or full-thickness and invariably require early surgery with skin grafts.

Physical examination

Patients with facial burns should be seen by an ophthalmologist as soon as possible to assess the extent of injury and to exclude the possibility of an ocular, intraocular, or intraorbital foreign body. The presence of a contact lens should not be overlooked. This assessment should be made, if possible, in the emergency room before significant conjunctival and eyelid edema prevents a thorough exam.

The most critical issue for the ophthalmologist is the integrity of the corneal surface. Therefore, a proper corneal evaluation should be performed using fluorescein strips and a cobalt blue light in the emergency room or burn unit.

The depth and extent of burns in the eyelid and facial area should be initially assessed, and documented with photography if possible. In the presence of a partial-thickness burn, eyelid contracture producing progressive lagophthalmos and corneal exposure is likely. Therefore, the presence or absence of a Bell’s phenomenon should be documented.

It has been suggested that intraocular pressure (IOP) monitoring may be important in the patient who receives intravenous fluid resuscitation, as elevation may occur within 72 hours of large shifts from the intravascular compartment to the extravascular compartment.

Management

Lubricating antibiotic eyedrops and ointments, moisture chambers, and frequent evaluation of both the globes and the eyelids are part of the early treatment of these patients. Once cicatricial changes begin in the eyelids, a relentless and rapid deterioration of the patient's ocular status often ensues secondary to cicatricial eyelid retraction, lagophthalmos, and corneal exposure. Head elevation may be helpful in preventing further swelling around the eyelids. Topical steroids should be avoided due to the risk of secondary infection.


General treatment

  • Lubrication within 24 hours of admission, with a minimum of three applications a day, is particularly important as burn patients often have reduced tear production, blink reflex, and eyelid mobility or excursion.
  • Singed or scorched eyelashes are usually present in a thermal eyelid burn and should be removed to avoid the possibility of char falling into the eye and prolonging ocular surface discomfort.
  • The principles of wound management for eyelid burns are those for any burn: assessment, cleansing, and protection followed by resurfacing for deeper burns.
  • In the presence of lagophthalmos with a severe burn of the eyelid skin, a suture tarsorrhaphy is useful and effective in aiding closure.
  • In the past, skin grafting was usually delayed until the cicatricial changes stabilized, but the early use of full-thickness skin grafts, amniotic membrane, and various types of flaps can effectively reduce ocular morbidity in selected patients.


Long term management includes retraction repair with skin grafts, repair of medial canthal deformities, trichiasis, palpebral aperture stenosis, eyebrow deformities, canalicular obstruction, and surgical or laser scar revision.

References

  1. Achauer BM, Adair SR. Acute and reconstructive manage- ment of the burned eyelid. Clin Plast Surg. 2000;7:87-95
  2. Barrow RE, Marc KM, David H. Early release of third-degree burns prevents eye injury. Plast Reconstr Surg. 2000;105(3): 860-3
  3. Bouchard CS, Morno K, Jeffrey P, et al. Ocular complications of thermal injury: a 3-year retrospective. J Trauma. 2001; 50(1):79-82
  4. Cole JK, Engrav LH, Heimbach DM, et al: Early excision and grafting of face and neck burns in patients over 20 years. Plast Reconstr Surg 2002; 109: 1266-1273
  5. Raman M., Ijaz S, and Baljit D. The management of Eyelid Burns. Survey of ophthalmology. Volume 54. June 2009
  6. Orbit, eyelids, and lacrimal system. (2012). San Francisco, CA: American Academy of Ophthalmology.