Eyelid Laceration

Lid lacerations are classified by depth and location.

• Superficial (skin and orbicularis only), involving the lid margin, involving the canaliculus (medial third), deep with levator or septal penetration, and with tissue loss.
• Lid margin and canalicular lacerations need anatomical repair to avoid notching, trichiasis and epiphora.
• Medial lacerations involve the canalicular system in about 15 to 25 percent of cases of lid trauma.

• Visible wound, with gaping, margin step or notch, tissue loss, and fat prolapse.
• Medial wound with epiphora indicates probable canalicular disruption.
• Ptosis suggests levator aponeurosis or muscle injury; vertical wounds crossing the upper lid margin are particularly at risk.
• Deep lateral wounds can injure the lacrimal gland, causing later dry eye.
• Look for exposed globe, scleral laceration and uveal prolapse.

• Full ocular assessment: acuity, pupils for a relative afferent defect, motility, and a dilated retinal examination. Do not press on a possibly ruptured globe.
• Canalicular assessment: probe and irrigate under magnification once the patient is anaesthetised; visualise the cut end by direct inspection, or retrograde probing from the other canaliculus with a Bowman probe. Do not force probing.
• CT for suspected foreign body, fracture or intracranial extension.

• Local anaesthesia: lidocaine 1 to 2 percent with adrenaline 1 in 100,000 (maximum 7 mg/kg with adrenaline). Use general anaesthesia in children, extensive wounds, and canalicular repairs.
• Superficial wounds: 6-0 or 7-0 non-absorbable (nylon) or fast absorbing (plain gut) interrupted skin sutures; remove at 5 to 7 days.
• Lid margin repair:
  • Align the grey line first with a 6-0 silk suture left long, then place a lash line suture.
  • Close tarsal plate with partial thickness 6-0 absorbable sutures (Vicryl) placed in lamellar fashion, not penetrating through the conjunctiva.
  • Close orbicularis and skin with 6-0 to 7-0 sutures. Keep knots away from the cornea.
• Levator injury: repair aponeurosis to the tarsus with 6-0 absorbable sutures, fat identifies septal breach; do not suture the septum.
• Canalicular laceration: repair within 24 to 48 hours under operating microscope.
  • Identify cut ends, intubate with a bicanalicular silicone stent or monocanalicular stent (Mini Monoka), pass through nasolacrimal system.
  • Approximate the canaliculus with 8-0 absorbable sutures at the pericanalicular tissue, repair the medial canthal tendon with a 4-0 non-absorbable suture to the posterior lacrimal crest.
  • Leave the stent in place for 3 to 6 months. Complications include stent extrusion and granulomas.
• Tissue loss: up to one quarter of the lid margin can usually be closed directly (lateral cantholysis helps up to one third); larger defects need a Tenzel semicircular flap, Hughes tarsoconjunctival flap or Cutler-Beard bridge flap for upper lid.
• Antibiotic ointment (chloramphenicol 1 percent twice daily for 1 week) and tetanus prophylaxis.