EYELID LACERATION

Signs and Symptoms

Patients with eyelid lacerations will present with varying degrees of eyelid swelling, edema, ecchymosis and bleeding.1 Eyelid lacerations can result from blunt force, cutting injury, extreme irritation secondary to dryness, constant epiphora (from surface or allergic disease) or from blepharitis infection resulting in a fissure at the juncture of the lateral eyelid corners.2-4 In traumatic cases, blow-out fracture and canalicular laceration can occur simultaneously as a result of the same trauma.1 Lower lid canalicular lacerations are common in cases involving concomitant blow-out fractures, particularly those involving the medial wall.1 Similar to most traumatic injury data, ocular eyelid injuries occur with greater frequency in young males.2,3 The mode of injury is also variable, with numerous documented causes.5-7 Since the forces necessary to disrupt the anatomy of the eyelid are significant, simultaneous globe injury is possible and must be considered.6-8 Depending on the etiology, eyelid lacerations should be probed or imaged to rule out the presence of retained foreign matter.5-8

Pathophysiology

The eyelid and ocular adnexa is well vascularized, containing multiple tissue types and sensory nerves. These elements are housed between the palpebral conjunctiva and the dermis.9-14 The external epidermis consists of multiple layers and lies over the elastin-rich dermis and subcutaneous layer, which contains adipose tissue, connective tissue, vessels and nerves.9,10 The striated muscle bundles of the orbicularis oculi lie deep to this, expanding throughout the eyelid.8,10 The submuscular areolar layer lies posterior to the orbicularis, becoming a boundary separating the orbicularis muscle from the tarsal plate.8,9 Tendonous fibers of the levator aponeurosis (LA, anterior and posterior portion) arise from the levator palpebrae superioris muscle (LPS) of the upper eyelid to course anteriorly, running between the orbicularis muscles. The anterior LA inserts superoanteriorly into the subcutaneous tissue, while the posterior LA inserts anteriorly into the eyelid skin itself and posteriorly over the entire width of the tarsal plate.10 Whitnall’s ligament and the intermuscular transverse ligament (ITL) originate from the trochlear portion of the medial wall of the orbit and insert into the lateral orbital wall.10 This ligament complex is thought to increase leverage by translating horizontal action into a vertical lifting action.10 The muscle of Müller (responsible for eyelid opening, under sympathetic innervation) rides underneath the LA.10

The protective tarsal plate is composed of dense connective tissue designed to provide the lid with rigidity and shape.9-14 This also allows the lid to maintain a posture aligned with the curvature of the globe.9 Sebaceous meibomian glands, which produce tear evaporation-reducing oil, are embedded in the tarsus.9 Zeis and Moll glands, also contributory to ocular surface support, are associated with eyelash follicles.

The nasolacrimal drainage system is contained in the medial-most portions of each eyelid, and the puncta define the outer most boundary.15,16 Tear flow is contained and maintained secondary to the tonicity of the lower lid via the muscle of Riolan (pars ciliaris portion of the orbicularis oculi).17 The tears flow into the puncta and into the superior and inferior canaliculi, which extends and expands 2mm in the vertical direction, then medially to the anatomic reservoir at the base of each canalicular arm, known as the ampula.15,16

Disruption of the external skin (abrasion, laceration or incision) can allow external pathogens access to the body. This creates the potential for infection (preseptal and orbital cellulitis). Lacerations that extend deeper or laterally have the potential to traverse the nasolacrimal apparatus, eyelid glands, extraocular muscles and tendons.17 Extensive lacerations have the capability of extruding fat, producing functional and cosmetic consequences.17,18 Life-threatening intracranial complications such as brain swelling can develop from blunt injuries that produce epidural hemorrhage.19

During the proliferative stage of wound healing, fibroblasts fill in the wound with collagen in a process termed granulation.20 New blood vessels replace vasculature that was lost to trauma. Epithelial cells from the wound margins migrate across the laceration toward the center of the wound. Myofibroblasts then cause contraction of the wound, resulting in shrinkage and apposition of the edges. The wound gradually contracts and is covered by a layer of skin.20 In the maturation and remodeling stage, collagen formation and remodeling strengthens the scar.20 Scar tissue is never as strong as original tissue, but it increases over time from 5% tensile strength to nearly 80%.20

Management

Patients presenting with eyelid lacerations require first aid. The first step is controlling bleeding or stabilizing impaling material. Impaling material should never be extracted, instead it should be stabilized. Once hemostasis has been achieved, attention can be directed to the globe and internal tissues. History is critical in determining the likelihood of retained particulate foreign matter. The area of injury should be inspected to rule out the presence of air (crepitus/orbital emphysema), which would increase the suspicion of bone fracture. Acuity measurement, slit lamp evaluation and tonometry will assist in fully assessing the possibility of globe damage. Dilated ophthalmoscopy should be completed unless a contraindication such as lens subluxation or globe rupture is suspected.

Lacerations created via bite, scratch or lesions with an accompanying bone fracture demand oral antibiotic prophylaxis, usually with a penicillin derivative such as phenoxymethylpenicillin 250mg BID PO. Amoxicillin, dicloxacillin and erythromycin 500mg BID PO are suitable as well.17,21 While infection is a risk with sutures, one study found primary suturing of wounds caused by animal bites resulted in infection rates similar to non-suturing, with better cosmetic results on head and facial wounds.22

Small abrasions or cuts without evidence of fat or orbicularis evulsion and lateral fissures not caused by trauma can be repaired using topical ophthalmic antibiotic ointment BID-TID with closure enhanced via the application of Steri-strips (3M) or skin tape where necessary.17,20 Pain management for cases that are not referred for repair can be accomplished by cold compresses and over-the-counter analgesics such as acetaminophen or ibuprofen. If severe ecchymosis or poorly controlled bleeding is present, avoid the use of aspirin or NSAIDs for pain control. Occasionally, narcotic analgesics may be needed for adequate pain management.

Tissue adhesive (cyanoacrylate glue) is not recommended, as it has the potential to produce unwanted adhesions. Uncomplicated wounds can be healed using light-activated sutureless substances in a process known as photochemical technique.23 Complicated lacerations or those involving the nasolacrimal apparatus require the skill of an oculoplastic surgeon.24-27 In these circumstances, after hemostasis and first aid has stabilized the injury, the eye should be lightly covered with a dressing and protected with a Fox (JedMed) or similar aluminum or plastic eye shield and promptly referred to an expert who has the skill to complete the restoration.

Clinical Pearls

The forces necessary to disrupt the anatomy of the eyelid skin and adnexa are significant; simultaneous injury to the globe and internal ocular contents is possible and must be ruled out.

Injuries with proximity to muscles can result in alterations in eyelid function and mobility.

Any laceration produced by a bite or scratch should include treatment with an oral prophylactic broad-spectrum antibiotic.

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3. Hwang K, Huan F, Hwang PJ, Sohn IA. Facial lacerations in children. J Craniofac Surg. 2013;24(2):671-5.

4. Naik MN, Kelapure A, Rath S, Honavar SG. Management of canalicular lacerations: epidemiological aspects and experience with Mini-Monoka monocanalicular stent. Am J Ophthalmol. 2008;145(2):375-380.

5. McCulley JP, Shine WE, Aronowicz J, et al. Presumed hyposecretory/ hyperevaporative KCS: tear characteristics. Trans Am Ophthalmol Soc. 2003;101(1):141-52.

6.Howden J, Danks J, McCluskey P, et al. Surfboard-related eye injuries in New South Wales: a 1-year prospective study. Med J Aust. 2014;201(9):532-4.

7. Mayercik VA, Eller AW, Stefko ST. Ocular injuries in all-terrain-vehicle accidents. Injury. 2012;43(9):1462-5.

8. Shah AD, Decock C. Occult orbito-cranial penetrating injury by pencil: Role of beta tracer protein as a marker for cerebrospinal fluid leakage. Indian J Ophthalmol. 2011;59(6):505–7.

9. Deprez M, Uffer S. Clinicopathological features of eyelid skin tumors: a retrospective study of 5504 cases and review of literature. Am J Dermatopathol. 2009;31(3):256-62.

10. Ng SK, Chan W, Marcet MM, et al. Levator palpebrae superioris: an anatomical update. Orbit. 2013;32(1):76-84.

11. Remington LA. Ocular adnexa and lacrimal system. In: Remington LA. Clinical anatomy of the visual system. 2nd ed. St. Louis, MO: Elsevier; 2005:160-5.

12. Sirigu P, Shen RL, Pinto-da-Silva P. Human meibomian glands: the ultrastructure of acinar cells as viewed by thin section and freeze-fracture transmission electron microscopes. Invest Ophthalmol Vis Sci. 1992;33(7):2284.

13. Jakobiec FA, Iwamoto T. The ocular adnexa: lids, conjunctiva, and orbit. In: Fine BS, Yanoff M, eds. Ocular histology. 2nd ed. New York, NY: Harper & Row; 1979:290.

14. Warwick R. Comparative anatomy of the eye. In: Warwick R, Wolff E. Eugene Wolff’s anatomy of the eye and orbit. 7th ed. Philadelphia: Saunders.; 1976:181.

15. Francisco FC, Carvalho AC, Francisco VF, et al. Evaluation of 1000 lacrimal ducts by dacryocystography. Br J Ophthalmol. 2007;91(1):43-6.

16. Oyster CW. The eyelids and the lacrimal system. In: Oyster CW. The Human Eye Structure and Function. Sunderland MA: Sinauer Associates; 1999:291-320.

17. Green JP, Charonis GC, Goldberg RA. Eye lid trauma and reconstruction techniques. In: Yanoff M, Duker JS. Ophthalmology. St. Louis, MO: Mosby-Elsevier; 2009:720-7.

18. Karabekir HS, Gocmen-Mas N, Emel E, et al. Ocular and periocular injuries associated with an isolated orbital fracture depending on a blunt cranial trauma: anatomical and surgical aspects. J Craniomaxillofac Surg. 2012;40(7):e189-93.

19. Noda E, Inoue M, Yoshikawa-Kobayashi I, Nagamoto T. Perforating eyelid injury extending to the brain stem in a 17-year-old woman: a case report. J Med Case Rep. 2010;4(1):18.

20. Chang EL, Rubin PAD. Management of complex eyelid lacerations. Int Ophthalmol Clin. 2002;42(3):187-201.

21. Wei LA, Chen HH, Hink EM, Durairaj VD. Pediatric facial fractures from dog bites. Ophthal Plast Reconstr Surg. 2013;29(3):179-82.

22. Paschos NK, Makris EA, Gantsos A, et al. Primary closure versus non-closure of dog bite wounds: a randomised controlled trial. Injury. 2014;45(1):237-40.

23. Yang P, Yao M, DeMartelaere SL, et al. Light-activated sutureless closure of wounds in thin skin. Lasers Surg Med. 2012;44(2):163-7.

24. Leibovitch I, Kakizaki H, Prabhakaran V, Selva D. Canalicular lacerations: repair with the Mini-Monoka monocanalicular intubation stent. Ophthalmic Surg Lasers Imaging. 2010;41(4):472-7.

25. Salgarelli AC, Bellini P, Landini B, et al. A comparative study of different approaches in the treatment of orbital trauma: an experience based on 274 cases. Oral Maxillofac Surg. 2010;14(1):23-7.

26. Timoney PJ, Stansfield B, Whitehead R, et al. Eyelid lacerations secondary to caesarean section delivery. Ophthal Plast Reconstr Surg. 2012;28(4):e90-2.

27. Sagili S, Malhotra R. Skin contracture following upper eyelid orbiculectomy: is primary skin excision advisable? Orbit. 2013;32(2):107-10.