AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Numerous mechanisms of blunt and penetrating facial trauma may result in eyelid lacerations. Even seemingly innocuous blunt objects in the workplace can cause eyelid lacerations in experienced workers.

Eyelid lacerations may (1) involve the lid margin, requiring a meticulous suture technique; (2) be extramarginal; or (3) cause tissue loss.

Proper management includes the following: excluding any accompanying injury to the globe, excluding a foreign body, protecting the cornea, maintaining proper lid dynamics, and optimizing cosmesis.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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History

• The ophthalmologist usually is not called to the emergency room until life-threatening injuries are stabilized. The ophthalmologist should still take a thorough history and carefully review the notes of the other trauma physicians. Record standard information, such as the last oral intake, allergies, and tetanus status.
• Ascertaining the mechanism of injury is important, as this may indicate associated injuries (eg, cervical trauma), the depth of the ocular adnexal injury, and possibly a foreign body.
• • Windshield-related accidents may be associated with a foreign body and tissue loss.
  • Bite wounds may implicate infection (eg, rabies) and tissue loss. In human bite wounds, determine the assailant's HIV and hepatitis status.
  • In patients with small penetrating lid lacerations, maintain a high index of suspicion for underlying globe trauma.
• Document prior visual function, the time of the injury, use of safety glasses, and accident witnesses.
• In some cases, pertinent history may not be revealed to the clinician.
• • Patients who are inebriated or under the influence of recreational drugs may not be good historians. Confirmation with family members or acquaintances may be required.
  • Children might conceal the details of their injury for fear of parental rebuke or implicating a playmate who caused the injury. Be especially wary of underlying foreign bodies in children.
  • Consider spousal or parental abuse.

Physical

• The patient's airway, breathing, circulation, and cervical spine should be cleared before addressing ocular adnexal trauma. Perform a quick gestalt of the patient, and review the vital signs. Precede lid repair with a thorough eye examination to exclude globe rupture.
• • If no globe rupture is present, evert the lids and flush the fornices, if needed. If the lids are markedly edematous, Desmarres retractors will aid in ocular examination. (If a Desmarres retractor is unavailable, a bent paper clip may be used.) Palpate and examine the lids for foreign bodies, including contact lenses.
  • Hyphema, orbital fractures, and other ocular adnexal trauma often occur with lid trauma.
• Exclude injury to the levator, medial canthal tendon, lateral canthal tendon, canaliculi, and supraorbital nerve.
• The presence of orbital fat indicates disruption of the septum and possible injury to the levator. In conscious patients, test levator function by splinting the brow and asking the patient to look up and down.
• Displacement or rounding of the canthal angles suggests canthal ligament injury.
• If the puncta are displaced or lacerations medial to the puncta are present, probe the canaliculi.
• In patients with superonasal lacerations near the orbital rim, test for supraorbital anesthesia prior to anesthetic injection.
• Diagram and measure lid lesions. Photograph the lid lesion, if appropriate. Patients may not realize the extent of their injury, and photography may aid in later compensation issues.
• If occult foreign body is suspected, obtain neuroimaging studies.
• The patient and family members should be given specific preoperative counseling regarding the possibilities for vision loss, lid malposition, cutaneous scarring, and possible need for further surgery. Patients should understand that some degree of scarring will result even with meticulous oculoplastic repair.
• In patients with glass or windshield injuries, occult, embedded glass may chronically extrude. Inform patients of this possibility.

Causes

See Background.

DIFFERENTIALS

Section 4 of 11  

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• Differentials
• Workup
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• Medication
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• Multimedia
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Other Problems to be Considered

• 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. Dysgonic fermenter type 2 is a potentially life-threatening virulent infection that can result after dog bites.
  • Wound debridement and copious irrigation (eg, bacitracin) is 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.

WORKUP

Section 5 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Document drug screen and blood alcohol level when appropriate. If a risk of HIV or hepatitis transmission is present, perform baseline serology.

Imaging Studies

• CT scan may confirm or reveal foreign bodies, a retrobulbar hemorrhage, a globe rupture, or an orbital fracture.
• • Depending on the size and lead content, glass foreign bodies may or may not be seen on radiography.
  • Orbital wood foreign bodies can be difficult to detect but may appear isodense with orbital fat. If no metallic foreign body is present and yet orbital wood is suspected but not seen on CT scan, an orbital MRI should be obtained.

TREATMENT

Section 6 of 11  

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• Follow-up
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Medical Care

• Infections, including periorbital necrotizing fasciitis (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.

Surgical Care

• 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.
• • Epinephrine is a relative contraindication in patients with sickle cell disease.
  • 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. 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.
• • Bicanalicular stents, such as Crawford/Ritleng tubes, are commonly used and readily available. Monocanalicular stents (eg, Mini Monoka) are becoming increasingly popular.
  • 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. Tighten the bicanalicular stent prior to tying the sutures to decrease suture tension.
• Lacerations of the deep head of the medial canthal ligament cause telecanthus (unlike lacerations of the superficial head of the canthal ligament).
• • 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 anatomical realignment. The author prefers to use a single vertical mattress stitch of 6-0 silk or 6-0 polyglactin to realign the lid margin. Traditionally, however, three 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.
  • If the antemarginal tarsus is lacerated, two or three 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.
  • The 6-0 fast-absorbing gut suture often is suggested in children who may not cooperate for later stitch removal. 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 day 5, and Steri-Strips are 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 anatomical 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. 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.
  • 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 sometimes is 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.

MEDICATION

Section 7 of 11  

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The goal of pharmacotherapy is to reduce morbidity and to prevent complications.

Drug Category: Topical steroid and antibiotic combination ointments

Reduce inflammation and prevent the development of infections.

FOLLOW-UP

Section 8 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

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

Complications

• Lid notching and epiphora may occur.

Patient Education

• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Black Eye.

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• Whenever possible, photodocument the injury. Patients and family members may fail to appreciate the extent of the initial injury that is obscured by blood or a patch.
• Carefully exclude an underlying globe rupture or foreign body.
• Early repair will reduce the incidence of epiphora and lid notching.

MULTIMEDIA

Section 10 of 11  

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• Miscellaneous
• Multimedia
• References

Media file 1:  Extramarginal upper lid laceration from blunt trauma in an infant. Such lacerations tend to follow relaxed skin tension lines.
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Media file 2:  Penetrating lid trauma with extensive periorbital ecchymosis. A ringlike projectile was ejected from a pipe fitting under high pressure. The patient also experienced choroidal rupture and traumatic optic neuropathy.
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Media file 3:  Preoperative. This child had a dog bite injury with a double lower lid margin laceration, dehiscence of the lateral canthal tendon, and disruption of the inferior canaliculus.
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Media file 4:  Postoperative. The inferior canaliculus was repaired with bicanalicular stenting. Lateral canthus reattachment and repair of lid margin lacerations was performed.
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Media type:  Photo

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Balaggan KS, Goolamali SI. Periorbital necrotising fasciitis after minor trauma. Graefes Arch Clin Exp Ophthalmol. Feb 2006;244(2):268-70. [Medline].
• Dagum AB, Antonyshyn O, Hearn T. Medial canthopexy: an experimental and biomechanical study. Ann Plast Surg. Sep 1995;35(3):262-5. [Medline].
• Gonnering RS, Kindwall EP, Goldmann RW. Adjunct hyperbaric oxygen therapy in periorbital reconstruction. Arch Ophthalmol. Mar 1986;104(3):439-43. [Medline].
• Green BF, Kraft SP, Carter KD, et al. Intraorbital wood. Detection by magnetic resonance imaging. Ophthalmology. May 1990;97(5):608-11. [Medline].
• Ing E, Ing T, Emara B. Ocular adnexal injuries from industrial blunt hook trauma. Can J Ophthalmol. Apr 2002;37(3):177-8. [Medline].
• Perry JD, Aguilar CL, Kuchtey R. Modified vertical mattress technique for eyelid margin repair. Dermatol Surg. Dec 2004;30(12 Pt 2):1580-2. [Medline].
• Stevenson TR, Thacker JG, Rodeheaver GT, et al. Cleansing the traumatic wound by high pressure syringe irrigation. JACEP. Jan 1976;5(1):17-21. [Medline].

Article Last Updated: Jan 8, 2007