Eyelid Laceration

From EyeWiki


Disease Entity

Disease

Eyelid lacerations refer to partial- or full-thickness defects in the eyelid and constitute a significant subset of facial trauma which is often accompanied by other ocular injuries including corneal abrasions, disruption of the lacrimal drainage system, foreign bodies, open globe, or orbital fractures.[1] As lid damage may be associated with serious ocular injury not apparent on initial exam, lacerations or other injuries to lid structures should prompt a thorough investigation to exclude potentially serious underlying ocular pathology.[2]

Etiology

Lid lacerations occur as a result of two general mechanisms including (1) contact with sharp objects moving at high velocities that either penetrate superficial structures (skin, subcutaneous tissues) and result in a partial-thickness defect or that penetrate deeper structures (posterior layers, tarsus, conjunctiva) resulting in a full-thickness defect and (2) avulsion injuries from blunt trauma.[3] Most injuries occur in children or young adults with dog bites, falls, handlebar injuries, and collisions with sharp objects being the most frequent cause of lid lacerations in children and blunt trauma from fists, motor vehicle accidents, eye gouging, and ball sports being the most frequent causes in adolescents and adults.[4][5][6]

Risk Factors

  • Sex [7]
    • Males are more likely to experience eyelid lacerations than females, perhaps because males are more likely than females to engage in physical violence, perform manual labor jobs, and play high-risk sports
  • Age
    • The eyelids are involved in approximately 20% of facial lacerations in the pediatric patient population [8]
    • The highest incidence of eyelid lacerations occurs among children, adolescents, and young adults[7]
    • Elderly individuals are at increased risk of falling, potentially increasing their risk of damage to the eyelids
  • Environmental exposures
    • Dogs (particularly the Pit Bull Terrier breed)[9]
    • Fist fighting
      • Either due to direct eyelid injury or avulsion
    • Using intoxicants
    • Mode of transportation
      • An increased incidence of eyelid lacerations has been reported in developing countries and elsewhere where the predominate mode of transportation is light motor vehicles[7]
    • Work environment
      • Trauma occurs more often at the workplace than at home[10]
      • Eyelid trauma has been reported to be of higher incidence among less-skilled workers than even children, young adults, and men[7]
      • Environments with heavy machinery, object moving at high velocities, hooks at eye level increase the potential for lid lacerations
    • Other
      • Birth trauma during cesarean section[11]

Primary prevention

Prevention is accomplished by minimizing trauma to the face. Children should be supervised at home and at school, particularly when playing with dogs, sharp objects, or riding bicycles.[6] Adolescents and adults should be counseled to use protective eyewear when engaging in high risk work or sporting activities and to wear protect headgear when riding light motor vehicles.[5][7] The elderly should avoid medications or activities that can increase the likelihood of falling and assure their environment minimizes fall/slipping risks.

Anatomy and Physiology

Effective management of eyelid lacerations requires a thorough understanding of the anatomy and physiology of the eyelid and surrounding facial structures. Of note, the number of layers and their relationship to one another within the eyelid changes significantly based the level of the lid examined. The most superficial layer of both the upper and lower eyelids is the skin. Eyelid skin is continuous with the skin of other facial structures and is unique in that it is the thinnest layer of skin on the body, containing no subcutaneous fat.

Immediately deep to the skin is the orbicularis oculi muscle which functions as the main protractor of both the upper and lower eyelids. The orbicularis oculi muscle is a thin, circular muscle innervated by cranial nerve VII and divided into pretarsal, preseptal, and orbital parts depending its location relative to deeper structures. Pretarsal and preseptal portions are responsible for involuntary eyelid closure and aid in the lacrimal pump mechanism while the orbital portion allows for voluntary eyelid closure.[12][13]

Both upper and lower eyelids also contain a tarsal plate and conjunctiva. The tarsal plates help maintain the structural integrity of the eyelids, act as attachment points for the lid retractors, and house the Meibomian glands and eyelash follicles. The conjunctiva, a layer of non-keratinizing squamous epithelium, is the deepest of the eyelid structures and serves several vital functions, including protecting posterior ocular structures, secreting mucin into the tear film, and providing accessory tears to maintain adequate lubrication.

Upper eyelid

In terms of vasculature, the upper lid is usually supplied by both marginal and peripheral vascular arcades[14] with the marginal arcade located anterior to the tarsal plate approximately 2 millimeters superior to the eyelid margin and the peripheral arcade located along the peripheral border of the tarsus near Muller’s muscle. Deep to the skin and orbicularis oculi approximately 10 millimeters superior to the eyelid margin of the upper lid lies the orbital septum, a thin fibrous layer of tissue which separates preaponeurotic fat and other tissues from postseptal orbital structures by connecting the periosteum of the arcus marginalis to the levator aponeurosis above the superior tarsal border [14].[14] At this same level, the eyelid contains nasal and central fat pads, with the central fat pad acting as an important landmark for lid laceration repairs due to its position between the orbital septum and the levator aponeurosis. Immediately deep to the preaponeurotic fat are the levator aponeurosis anteriorly and Muller’s muscle posteriorly, both of which originate from the apex of the orbit and act as retractors of the upper eyelid. The levator aponeurosis receives innervation from cranial nerve III and extends inferiorly to approximately 5 millimeters superior to the upper eyelid margin, eventually inserting into the pretarsal orbicularis muscle, skin, and anterior portion of the superior tarsus.[14] Muller’s muscle is sympathetically innervated and also extends inferiorly to approximately 10 millimeters above the upper eyelid margin, eventually inserting along the superior tarsal margin.[12][14]

Lower eyelid

The lower lid receives blood mainly from the peripheral vascular arcade which lies along the peripheral border of the tarsus near the inferior tarsal muscle.[14] The lower lid can be divided into an upper 5 millimeters and a lower 5 millimeters. The upper 5 millimeters contains, from superficial to deep, the following four layers: skin, pretarsal orbicularis oculi, tarsal plate, and conjunctiva. The lower 5 millimeters contains, from superficial to deep, the following seven layers: skin, preseptal orbicularis oculi, orbital septum, precapsulopalpebral fascia fat (three fat pads: nasal, central, and temporal), capsulopalpebral fascia (analogous to levator aponeurosis of upper lid), inferior tarsal muscle (analogous to Muller’s muscle), and conjunctiva. The capsulopalpebral fascia originates from the inferior rectus muscle, extends forward to envelop the inferior oblique muscle, and attaches along with the inferior tarsal muscle to the tarsal plate with innervation from cranial nerve III. The inferior tarsal muscle is poorly developed and runs posterior to the capsulopalpebral fascia to its insertion into the lower lid tarsal plate with innervation from sympathetic nerves.[12][13][14]

Nasolacrimal system

Canalicular lacerations are an important subset of eyelid lacerations and should be suspected in any trauma involving the periorbital tissues, especially the medial aspect of the eye or blunt trauma to the zygoma. The nasolacrimal system is a mechanism for draining fluid from the surface of the eyes and consists of puncta located at the medial aspects of the superior and inferior eyelid margins, canaliculi located at the medial aspects of the superior and inferior eyelids that receive fluid from the puncta, a common canaliculus formed from the merger of the superior and inferior canaliculi, a lacrimal sac on the medial aspect of the orbit which receives fluid from the common canaliculus, and, finally, a nasolacrimal duct which drains fluid into the nose.

Please refer to the canalicular trauma page (https://eyewiki.aao.org/Canalicular_trauma) for more information about nasolacrimal anatomy and trauma.

Diagnosis

History

Review the condition of the patient’s eyes and eyelids before the injury based on the contralateral uninjuried eye or old photographs or driver’s license and note any allergies, last oral intake, and tetanus status. Determine the mechanism and timing of the injury and whether or not anything has already been done by the patient to treat the suspected injury. Investigate the likelihood of chemical or foreign body (including contact lenses) injury and if any protective eyewear was worn at the time of injury. For injuries involving bite wounds, investigate for rabies (dog wounds, endemic areas) and determine the perpetrator’s HIV and hepatitis status. Be aware that children and those who are or were under the influence of illicit or recreational drugs or alcohol may be poor historians, potentially requiring confirmation with parents, acquaintances, or other witnesses. Always maintain some index of suspicion for abuse or neglect and in cases of falls syncope may need to be considered if no clear mechanical cause.

Physical examination

Potential eyelid trauma. Complete a full ocular examination including visual acuity, pupillary size and reactivity, intraocular pressures, extraocular motility and alignment, confrontational visual fields, external exam, slit-lamp examination, and bilateral dilated fundoscopic examination. During the exam, special consideration should be given to excluding trauma to the globe, orbital soft tissues (including medial canthal tendon, lateral canthal tendon, levator, canaliculi, the optic nerve), and the intracranial compartment before attempting to repair the eyelid.[15][16]Additionally, sensory and motor function around the area of trauma should be evaluated. Injury to the motor nerves of the face, especially cranial nerve VII, can have serious adverse effects on overall ocular health.

To explore the wound and determine depth of penetration, carefully evert the eyelids with either cotton-tipped applicators (CTAs) or toothed forceps and flush the fornices if needed. For markedly edematous lids, use either Desmarres retractors or a bent paper clip.[16] If the puncta are displaced or a laceration is found medial to the puncta, perform punctal dilation and probing (irrigate if necessary) to rule out canalicular injury.

If at any time during the exam a foreign body is seen or suspected based on physical exam findings, mechanism of injury, or patient history, advanced radiological imaging is warranted. In cases of trauma when radiologic imaging is warrented, the initial radiologic testing should be CT not MRI.

Signs

  • Erythema, edema, or tissue disruption around the eyelid or surrounding structures
  • Erythema, edema, or tissue disruption near the zygoma (may result in avulsion of medial canthal tendon with concomitant disruption of the canalicular system)
  • Displacement of the punctum
  • Horizontal laceration with protruding preseptal fat and/or ptosis (indicates perforation of the orbital septum and possible damage to the levator aponeurosis)
  • Displacement, excessive rounding, or abnormal laxity of the medial canthus (may indicate medial canthal tendon avulsion)[15]
  • Injection of fluorescein dye into the canalicular system which fails to drain into the nasolacrimal system (indicates potential canalicular damage)

Symptoms

  • Pain or irritation emanating from the eye, eyelid, or surrounding facial structures
  • Bleeding or drainage from the eyelid or surrounding facial structures
  • Blurry or distorted vision
  • Supraorbital anesthesia (indicates possible laceration near the orbital rim)

Clinical diagnosis

Based on direct observation of laceration and physical exam findings

Diagnostic procedures

If any history or exam findings are suggestive of penetrating injury or severe blunt trauma, CT scan of the brain, orbits, and midface (axial, coronal, and parasagittal views, 1- to 2-mm sections) should be obtained to rule out ruptured globe, retained foreign body, fracture, or intracranial injury. If deeper injury is suspected, advanced imaging prior to lid laceration repair should be performed.[15] Note that while wood, plastic, and some types of glass will not be visible on plain x-ray or CT, MRI T-1 weighted imaging is a reliable method to visualize wooden foreign bodies but should not be the initial imaging modality after trauma.[17] Fluorescein injection into the canaliculi is useful in assessing damage to the nasolacrimal system.

Laboratory test

Appropriate laboratory tests should be ordered based on mechanism of injury and patient history. Record blood alcohol and toxicology screens if appropriate. In situations where HIV or hepatitis infection is suspected, perform baseline serologies. Given their proclivity towards causing chronic abscesses, vegetable foreign bodies should be cultured following removal.[16][17]

Differential diagnosis

The differential for lid lacerations includes periocular contusion, canthal tendon avulsion, lid avulsion. Concominant injury or disorders can also be present and includes an extensive list, including conjunctival abrasion, corneal foreign body, orbital fracture, orbital foreign body, and traumatic hyphema[18]

Management

General treatment

A working understanding of the general principles of eyelid management and repair is necessary for to a wide range of medical specialties. Primary repair of eyelids should be performed within 12 to 24 hours of the injury to reduce subsequent complications, with the first step in repair being copious wound irrigation with saline and removal of foreign particles visible on the surface of the skin and eyes to avoid infection and inflammation. Following copious wound irrigation and removal of surface particles, fibrin clots near wound edges should be cleared away to help promote tissue healing after primary repair. For best wound closure and healing, gently handle tissue edges, approximate wound edges such that there is slight eversion, and use the smallest diameter sutures that will reliably maintain the integrity of the wound closure. Lid sutures can generally be removed 4-7 days following repair, while sutures in the periorbital skin and lid margins should be left in place for 5-10 days. Although sutures can be removed relatively quickly, patients should be informed that complete wound healing and scar formation requires 6-12 months.[15][17]

Medical therapy

Treatment of eyelid lacerations is primarily surgical, but medical therapy should be employed when indicated. Systemic antibiotics (amoxicillin/clavulanate [500/125 mg b.i.d. to t.i.d. or 875/125 mg p.o. b.i.d.], doxycycline [100 p.o. b.i.d.], trimethoprim/sulfamethoxazole [80/400 mg or 160/800 mg daily to b.i.d.], or cephalexin [250 to 500 mg p.o. q.i.d.] [adults]; 25 to 50 mg/kg/day divided into four doses [children]) should be administered for contaminated wounds or if bites or foreign bodies are suspected. When applicable, consider tetanus or rabies prophylaxis.[15]

Medical follow up

Instruct the patient to complete the full course of antibiotics as prescribed. Monitor for signs and symptoms of infection in the post-operative period until sutures are removed and antibiotic treatment is completed. A full ocular examination, including visual acuity, pupillary size and reactivity, intraocular pressures, extraocular motility and alignment, confrontational visual fields, external exam, slit-lamp examination, and bilateral dilated fundoscopic examination should be completed in the post-operative period to monitor recovery.

Surgery

Prior to starting surgery, it is imperative to exclude ruptured globe, retained foreign body, fracture, or intracranial injury. CT or MRI imaging should be obtained if there is a suspected open globe injury, marked ecchymosis or periorbital edema, or suspected foreign body.[17] Once other injuries have been excluded, the wound can then be classified as either simple or complicated. Eyelid lacerations are considered complicated when they are full-thickness or involve a ruptured globe, intraorbital foreign body, the lacrimal draining system, the levator aponeurosis or superior rectus muscle, damage to the lid margin, visible orbital fat prolapse, medial canthal tendon rupture, or extensive tissue loss and should be repaired in an operating room by an ophthalmologist.[15] Simple eyelid lacerations, by definition, are lacerations which do not meet the criteria of a complicated laceration and can often be effectively managed by non-ophthalmologists or by ophthalmologists in a minor surgery room.

Procedure for superficial, simple eyelid laceration repair

Simple superficial lacerations that are horizontal, follow skin lines, and involve less than 25 percent of the lid can be effectively managed without surgery using triple antibiotic ointment or adhesives along the linear axis of the laceration.[19][20]

Procedure for surgical repair of simple eyelid lacerations

After placing topical anesthetic in each eye, place a protective scleral shell over the affected eye and a protective covering over the unaffected eye. Clean with full-strength povidone-iodine solution (Betadine), irrigate with normal saline to delineate the full extent of the wound, and isolate the area with surgical drapes. Administer the minimum required amount of local subcutaneous anesthesia to the affected area and provide sedation to uncooperative patients (i.e. children, demented, etc.). Close the wound with 6-0 or 7-0 nylon or prolene (non-absorbable) or 6-0 plain gut or chromic gut (absorbable) sutures. Non-absorbable sutures should be avoided in patient who are unlikely to be compliant to follow up (children, demented, homeless, etc.).

In terms of technique, use either simple, interrupted sutures or vertical/horizontal mattress sutures if the wound is under tension. Subcuticular sutures are preferred to simple, interrupted sutures to repair triangular flap tips to prevent tissue necrosis. When repairing ragged wound edges, focus on approximating key areas first, followed by the rest of the wound.[17] Avoid deep sutures between the tarsus and the orbital rim because they can incorporate into or perforate the orbital septum.

Procedure for surgical repair of eyelid margin lacerations

Careful and methodical repair of eyelid margin lacerations is exceedingly important for maintaining both the function and aesthetic integrity of the eyelid. When preparing to repair a laceration of the lid margin, the first steps include identifying the tarsus, grey line, anterior lash line, and the mucocutaneous junction. Once these important landmarks are delineated, the wound edges can be approximated with the appropriate instruments and the wound tension assessed (if the tension is too high when the wounds are approximated with instruments, a lateral canthotomy with cantholysis may be required). Align the tarsus along its vertical axis and place 6-0 silk sutures through the grey line on either side of the wound 2 millimeters from the wound edge, leaving the tails long. Use absorbable sutures patients for difficult or unreliable patients (children, demented, homeless, etc.). Next, use vertical mattress 5-0 or 6-0 Vicryl sutures to approximate the tarsus along its vertical axis, with three sutures for upper eyelid lacerations and two sutures for lower eyelid lacerations. Tie, trim, and bury the tarsal sutures along the vertical tarsal border. Place another 6-0 silk marginal sutures along the anterior lash line and possibly the mucocutaneous junction. Note that some sources advise a different sequence, placing either 6-0 or 7-0 silk sutures in the grey line, anterior lash line, and possibly the mucocutaneous junction after securing the vertical axis.[17] Finally, use interrupted 6-0 plain gut sutures to close the skin along the length of the wound. Bury the tails of the eyelid margin sutures which have been left long into the skin sutures such that they are kept away from the corneal surface. Once the procedure has been completed, remove any protective eye equipment that has been placed, apply appropriate antibiotics to the wound, and dress the wound as needed.

Please refer to the eyelid reconstruction page (https://eyewiki.org/Eyelid_Reconstruction) information regarding the surgical repair of eyelid lacerations(simple and margin involving).

Procedure for surgical repair of canalicular lacerations

Please refer to the canalicular trauma page (https://eyewiki.aao.org/Canalicular_trauma) for information regarding the surgical repair of canalicular lacerations

Procedure for surgical repair of canthal lacerations not involving canaliculi

The lateral canthal tendon inserts at the lateral canthal tubercle and, if damaged, can be repaired by wiring or suturing the tendon to the tubercle 1 to 2 millimeters higher than the medial canthus and slightly higher than the contralateral lateral canthus.[21] To avoid using metallic wire, 2-0 nylon can be passed through drill holes to secure the tendon.[17]

The medial canthal tendon inserts into two locations: the anterior and posterior lacrimal crests. If no fracture to the crest or surrounding structures is present, the tendon can by sutured or wired to the posterior lacrimal crest and the anterior head of the tendon sutured to the anterior lacrimal crest.[22]

Surgical follow up

Lid sutures can generally be removed 4-7 days following repair, while sutures in the periorbital skin and lid margins should be left in place for 5-10 days. Although sutures can be removed relatively quickly, patients should be informed that complete wound healing and scar formation requires 6-12 months. If a small notch is present, inform the patient that it will be followed for 3-6 months and will likely resolve without any further intervention.[15] At all follow up visits, thoroughly document the status of the surgical site and surrounding areas and manage patient expectations surrounding recovery of pre-trauma function and appearance.

Complications

The potential complications of lid repair surgery include lid margin notching, lagophthalmos, hypertrophic scars, infection, tearing, and traumatic ptosis.

Prognosis

Simple lacerations can be closed by direct suturing and generally have superb long-term results. Although complex lacerations extend into the deeper layers of tissue and require meticulous repair of multiple damaged layers, they also often have excellent long-term results.[23]

Additional Resources

None

References

  1. Walker RA, Adhikari S. Eye Emergencies. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.proxy.westernu.edu/content.aspx?bookid=1658&sectionid=109444274. Accessed June 15, 2019.
  2. Hatton MP, Thakker MM, Ray S. Orbital and adnexal trauma associated with open-globe injuries. Ophthalmic Plast Reconstr Surg. 2002;18(6):458.
  3. Flach AJ. Eye Injuries. In: LaDou J, Harrison RJ. eds. CURRENT Diagnosis & Treatment: Occupational & Environmental Medicine, 5e New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com.proxy.westernu.edu/content.aspx?bookid=1186&sectionid=66479396. Accessed June 14, 2019.
  4. Eyelid Lacerations in Children. (n.d.). Retrieved June 14, 2019, from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=90&contentid=P02085
  5. 5.0 5.1 5 Zagelbaum BM, Starkey C, Hersh PS, et al. The National Basketball Association eye injury study. Arch Ophthalmol 1995; 113:749.
  6. 6.0 6.1 6 Jung J, Braverman R. Eye. In: Hay, Jr. WW, Levin MJ, Deterding RR, Abzug MJ. eds. Current Diagnosis & Treatment: Pediatrics, 24e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.proxy.westernu.edu/content.aspx?bookid=2390&sectionid=189076415. Accessed June 14, 2019.
  7. 7.0 7.1 7.2 7.3 7.4 Tabatabaei A, Kasaei A, Nikdel M, et al. Clinical characteristics and causality of eye lid laceration in Iran. Oman Med J. 2013;28(2):97–101
  8. Hwang K, Huan F, Hwang PJ, Sohn IA. J Craniofac Surg. 2013. 24(2):671-5
  9. Wladis EJ, Dewan MA. Periorbital Trauma from Pit Bull Terrier Attacks. Orbit. 2012. 31(3):200-202.
  10. Wong TY, Klein BE, Klein R. The prevalence and 5-year incidence of ocular trauma. The Beaver Dam Eye Study. Ophthalmology 2000. Dec;107(12):2196-2202
  11. Timoney PJ, Stansfield B, Whitehead R, Lee HB, Nunery WR. Eyelid lacerations secondary to caesarean section delivery. Ophthalmic Plast Reconstr Surg. 2012 Jul-Aug;28(4):e90-2.
  12. 12.0 12.1 12.2 Cochran ML, Czyz CN. Eyelid Laceration. [Updated 2019 Mar 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www-ncbi-nlm-nih-gov.proxy.westernu.edu/books/NBK470367/
  13. 13.0 13.1 Vander, J. F., & Gault, J. A. (2007). Ophthalmology secrets in color. Philadelphia, PA: Mosby Elsevier.
  14. 14.0 14.1 14.2 14.3 14.4 14.5 Goodman, R. L. (2004). Ophtho notes: The essential guide. doi:doi:10.1055/b-005-148863
  15. 15.0 15.1 15.2 15.3 15.4 15.5 15.6 Wajda, B. (2017). The Wills Eye Manual. Lippincott Williams & Wilkins.
  16. 16.0 16.1 16.2 Ing, E. (2017, September 11). Eyelid Laceration Clinical Presentation: History, Physical, Causes. Retrieved June 15, 2019, from https://emedicine.medscape.com/article/1212531-clinical#b4
  17. 17.0 17.1 17.2 17.3 17.4 17.5 17.6 17 Green BF, Kraft SP, Carter KD, Buncic JR, Nerad JA, Armstrong D. Orbital Wood. Detection by magnetic resonance imaging. Ophthalmology 1990;95(5):608-611
  18. Swartz, J., Lu, K., Camilon, M., Holtz, M., Young, N., Ostermayer, D., . . . O'Brien, M. (2017, June 11). Eyelid laceration. Retrieved June 15, 2019, from https://wikem.org/wiki/Eyelid_laceration
  19. Chandler DB, Gausas RE. Lower eyelid reconstruction. Otolaryngol Clin North Am 2005; 38:1033.
  20. Brown DJ, Jaffe JE, Henson JK. Advanced laceration management. Emerg Med Clin North Am 2007; 25:83.
  21. Soll DB. Treatment of late traumatic eyelid problems. Trans Am Acad Ophthalmol Otolaryngol. 1976;81:0P560-565.
  22. Carroll RP.Management of eyelid trauma. In:Hornblass A, ed. Oculoplastic orbital, and reconstructive surgery. Baltimore: Williams & Wilkins, 1988;(1)45:409-414.
  23. Pargament JM, Armenia J, Nerad JA. Physical and chemical injuries to eyes and eyelids. Clinics in Dermatology. 2015. 33:234–237