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PG Corner

Management of eyelid lacerations

ABSTRACT
Eyelid lacerations form a major bulk of the ocular trauma that we see in our casualty. These are managed
differently depending on the depth, width, and location of the injury. Repairing of eyelid injuries requires
good anatomic knowledge and meticulous approach. This article gives a

brief overview of the practical aspects in Functional anatomy of the lid can be simplified by
dividing lid into two parts along gray line.
managing an eyelid laceration. Keywords: • Anterior lamella – eyelid skin and orbicularis muscle
• Posterior lamella – conjunctiva and tarsal plate.
Canalicular tear, eyelid laceration, margin tear Medial canthus and lateral canthus
Fibrous extension from the tarsal plate forms the canthal
tendons [Figure 2].[1] Canthal tendons maintain horizontal
INTRODUCTION pull on the lids to maintain proper lid apposition.

Eyelids are protective curtains in front of eyes which PREOPERATIVE EVALUATION

give shape and beauty to the face. Any defect or injury
to eyelids due to trauma or surgical excision needs to be First and foremost is a detailed history regarding the time,
meticulously repaired for the best possible cosmetic course, and circumstances of injury.
outcome. Road traffic accidents, blasts, and falls are the
major causes resulting in injuries to eyelids. Traumatic Rule out occult injuries
laceration to the eyelid requires a thoughtful, well- For full-thickness upper eyelid injuries, never forget to
planned approach in order to provide the best outcome check for globe perforations. Globe injuries should be
and reduce the chances of postoperative complications. attended before lid injuries. Eyelid trauma can be
associated with hyphema, angle recession, or retinal
SURGICAL ANATOMY detachment. Detailed ocular examination includes visual
acuity, ocular movements, intraocular pressure, pupillary
Eyelid margin reactions, and posterior segment examination.
Eyelid margin has a slightly rounded anterior edge and
sharp posterior edge. Anatomical structures in eyelid Clear watery discharge from one nostril indicates
margin are shown in Figure 1. cerebrospinal fluid rhinorrhea and is a red alert sign to
look for anterior skull base fractures.
Gray line lies anterior to meibomian gland openings and Rita Mary Tomy
represents an avascular plane between the orbicularis Oculoplasty and Neuroophthalmology Fellow, Little Flower
and the tarsal plate. It is the plane along which the lid Hospital, Angamaly, Kerala, India
can be spilt into two halves.
Address for correspondence: Dr. Rita Mary Tomy,
The Retreat, CN 203, Angamaly - 683 572, Kerala,
India. E-mail: [email protected]
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DOI:
10.4103/kjo.kjo_83_18 How to cite this article: Tomy RM. Management of eyelid lacerations.
Kerala J Ophthalmol 2018;30:222-7.
© 2018 Kerala Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
Wound inspection, cleaning, and documentation
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Tomy: Management of eyelid lacerations

We save all eyelid tissues, as high vascularity often allows or deep monitored anesthesia care for complex lacerations
for viable re-approximation of partially avulsed ocular involving the canaliculi, underlying bone fractures, and
adnexal tissue [Figure 3]. We photograph all preoperative when operating on young children.
injuries and immediate postoperative results.
PRINCIPLES OF LID REPAIR
A broad-spectrum prophylactic antibiotic cover is
preferred (such as amoxicillin-clavulanate or clindamycin 1. Wounds should be copiously irrigated and explored,
for the penicillin-allergic). Tetanus prophylaxis may also with the removal of any foreign material after local
be required. anesthesia
2. Reconstruction should be done in layers as per correct
Tear outflow system anatomical orientation
Blunt injury to the medial eyelid with resultant eyelid 3. Wounds should not be extended to explore structures
laceration almost always tears the canaliculus. Telecanthus unless the exploration is for suspected foreign body
is noted in case of outfracture of the lacrimal bone or 4. The orbital septum if damaged should never be
laceration of the medial canthal tendon. In eyelid repaired, as this may result in compromised eyelid
lacerations medial to the puncta, the canaliculi should be excursion and even lagophthalmos. We should avoid
probed to assess integrity [Figure 4]. We have found that suture incorporation of the septum during repair
most eyelid injuries can wait 24–48 h for soft-tissue 5. The presence of orbital fat raises the risk of deeper
swelling to improve. injury and foreign bodies
6. In brow lacerations, eyebrows should never be shaved
Anesthesia off as orientation of the brow hair will help us in
Most of our cases are operated under local anesthesia. correct approximation [Figure 5]
Facial block can be supplemented. We prefer general 7. Anterior lamellar defects not involving lid margin
anesthesia should be repaired by primary closure. [2] If required,
undermining of the surrounding skin was done to
mobilize skin for adequate closure. Interrupted
sutures with 6-0 vicryl may allow for hematoma
egress or infection drainage

Figure 1: Eyelid margin anatomy (illustration by Christine Gralapp)

Figure 2: Eyelids, deep dissection of structural elements

Figure 3: Avulsed eyelid laceration

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Tomy: Management of eyelid lacerations

Figure 4: Probing to assess canalicular integrity in medial tears The rounded configuration of the medial canthus and/or
8. We should repair deep tissues first. Posterior lamella the acute angle of the lateral canthus can be distorted or
(tarsus, retractors, and conjunctiva) repair is lost in canthal injuries [Figure 8]. The integrity of the
dependent on the extent of injury. Conjunctival canthal tendon is tested by grasping the lid with toothed
lacerations of 5 mm or less often do not need to be forceps and pulling toward the limbus.[3]
repaired unless there are apposing lacerations of the
bulbar and palpebral surface that may adhere forming
a symblepharon. We use 8-0 vicryl suture for larger
conjunctival lacerations
9. Primary repair of the levator aponeurosis is done by
repositioning it to the upper half of the tarsus with
permanent 6-0 or 7-0 suture material.

Full-thickness lid margin lacerations, canalicular tears, Figure 5: Brow laceration pre- and postrepair
canthal injuries, and lacerations with tissue loss are
entities which should be meticulously tackled using
specialized techniques.

EYE LID MARGIN REPAIR

• The wound should be carefully inspected to identify

tarsus and lid margin landmarks such as gray line,
anterior lash line, and posterior margin
• Repair should be carried out preferably under
operating microscope.

“THREE-SUTURE TECHNIQUE” Figure 6: Vertical mattress suture along the gray line

1. Vertical mattress suture along the gray line using 5-0

silk suture passed just like the traditional vertical
(“far-far then near-near”) mattress in line with the
meibomian orifices [Figure 6]. A good apposition a b c
with slight margin eversion should be the goal[3]
Figure 7: (a) Eyelid marginal tear. (b) Tear repaired by three suture
The tarsus is next closed with interrupted, partial-technique. (c) After suture removal at 2 weeks
thickness
6-0 vicryl sutures The avulsed lateral canthal tendon should be sutured or
2. Simple suture passed along the anterior lash line 3. wired at the tubercle so that it is 1–2 mm higher than the
Simple suture in the posterior mucocutaneous medial canthus.
junction.
The posterior limb of the medial canthal tendon is
All suture ends are left long. The anterior lamella of the primarily responsible for the medial canthal configuration.
eyelid is closed next, with interrupted sutures using 5-0 The ruptured tendon can be sutured to the posterior
silk. The long end of the margin sutures is buried into the lacrimal crest or as posterior as possible taking special
knots of these skin sutures to prevent the suture ends from care not to injure the lacrimal sac. The anterior head of the
abrading the cornea [Figure 7a and b]. Sutures are medial canthal tendon can be sutured directly to its
removed after 2 weeks [Figure 7c]. All tarsal irregularities anterior lacrimal crest insertion.
at the wound edges should be trimmed to allow good
tarsal-to-tarsal approximation which prevents tarsal EYELID INJURIES WITH TISSUE LOSS
buckling and postoperative notching of lid margin.
These are very rare.
REPAIR OF CANTHAL INJURIES

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Tomy: Management of eyelid lacerations

Full-thickness eyelid defects with tissue loss are classified REPAIR OF CANALICULAR LACERATION
depending on the horizontal extent of defect into[4]
Canalicular injury should be suspected in all lacerations
a. Small defects (<1/3) which are medial to the punctum [Figure 13]. All
canalicular lacerations should be repaired whether upper
b. Medium defects (1/3–1/2)
or lower under operating microscope. Identification and
c. Large defects (>1/2).
retrieval of the proximal end of canaliculus is the most
difficult step. Methods used are:
Repair of small defects (<1/3 of horizontal length)
Direct closure • Examination under high magnification
This is possible because of increased eyelid laxity, • Gentle irrigation of fluid or air injection through
uninjured canalicular system
especially in older patients.
• Dyes such as methylene blue or diluted fluorescein
Lateral canthotomy and cantholysis can also be used.
This provides additional horizontal lengthening in lateral
canthotomy, and horizontal limb of Y-shaped lateral
canthal ligament is incised. For cantholysis, inferior or
superior crus of lateral canthal tendon is incised.

Repair of moderate defects (up to 1/2 of horizontal length)

Tenzel semicircular flap
It can be used for both upper lid and lower lid defects
where some tarsus remains on either side of the defect. A
high arched semicircular flap of the skin and orbicularis
muscle is rotated from lateral canthus after lateral
cantholysis. The flap dimensions are 22 mm × 18 mm (V
× H). For upper lid defects, the semicircle extends
inferiorly, and for lower lid, the semicircle extends Figure 8: Lid laceration with medial canthal tendon injury
superiorly. After undermining of the tissue, the lid is
pulled medially and direct lateral canthus is created
[Figure 9].

Repair of large defects (>½ of horizontal length)

Cutler-Beard bridge technique
Originally described for reconstruction of the upper lid,
this technique can be used for reconstruction of the lower
lid defect also, a procedure known as reverse Cutler-
Beard.

Cutler-Beard procedure is done in two stages [Figure 10].

Hughes tarsoconjunctival flap technique

It is partial-thickness posterior lamellar flap harvested Figure 9: Tenzel semicircular flap
from upper lid to cover lower lid defects [Figure 11].

Mustarde cheek rotation flap

It is reserved for the reconstruction of very extensive
lower eyelid defects usually involving more than 75% of
the eyelid. The side of the triangle nearest the nose should
be practically vertical. The advantage of this procedure is
that it is a one-stage, complete lower lid reconstruction
[Figure 12].

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Tomy: Management of eyelid lacerations

a b

Figure 13: Parts of Mini-Monoka monocanalicular stent

c d

Figure 10: Cutler-Beard procedure Stage 1: (a) Full thicknes upperlid

defect. (b) A three-sided inverted U-shaped incision is marked on the
lower eyelid, about 5 mm below lid margin. (c) By a full-thickness
incision, the lower lid flap is pulled under the bridge of lower lid and
sutured in layers to the upper lid defect. Since this flap is devoid of the
tarsus, autogenous cartilage from the ear can be used. Stage 2: (d)
a b
Separation of the flap at 6 weeks to 3 months. After cutting the flap, lid
margin of newly formed upper eyelid is sutured with conjunctiva
covering the free margin.

Figure 12: Mustarde cheek rotation flap. (a) A large myocutaneous

cheek flap is dissected and used in conjunction with an adequate
mucosal lining posteriorly. (b) A deep inverted triangle must be excised
below the defect. The side of the triangle nearest the nose should be
a b practically vertical. (c) Adequate rotation and suturing of the flapto
cover the defect.
Figure 11: (a) Upper lid is everted, incision is made through tarsus 4 mm
above lid margin, and flap is mobilized. (b) Flap is sutured with lower
lid tarsus to create posterior lamella. Sufficient skin to cover the
anterior surface of the flap is obtained by advancing a myocutaneous
flap from surrounding skin

a b

Figure 14: (a) Medial lower eyelid laceration with canalicular tear.
(b) Canalicular tear repaired with Mini-Monoka stent (blue arrow)

If proximal end is crushed and cannot be retrieved, eyelid Mini-Monoka monocanalicular stents are used in our
should be closed without further manipulation. hospital with excellent postoperative results [Figures 13
and 14]. It has a self-retaining cap which sits at the
MATERIALS USED FOR CANALICULAR STENTING punctum giving it excellent stability and avoids extrusion
or displacement of stent. It also has the advantage of not
1. Crawford bicanalicular stents disturbing the uninjured canaliculus. Only disadvantage
2. Mini-Monoka monocanalicular stents is the high cost of stent.
3. Angiocath I/V cannula 22 gauge.
FOLLOW-UP

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Tomy: Management of eyelid lacerations

Sutures are generally removed as follows:

• -Low-to-moderate tension eyelid wounds at
5–7 days
• -Marginal sutures at 2 weeks
• -Mini-Monoka removal is done at 3 months.
At all follow-up visits, meticulous chart documentation is
critical, and supplemental photographic documentation is
desirable.

COMPLICATIONS

1. Lid margin notching

2. Lagophthalmos
3. Hypertrophic scars
4. Infections
5. Tearing 6. Traumatic ptosis.

CONCLUSION

Repairing of eyelid injuries is an art which requires good

anatomic knowledge and meticulous approach. Gentle
tissue handling and proper alignment should be done.
The aim should be to achieve the best possible functional
and cosmetic outcome. Always bear in mind that
“Primary repair is the best repair.”

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.
3.

REFERENCES
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Philadelphia: Saunders 1994:126.
Vichare N. Management of lid lacerations ocular trauma. Delhi
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Nelson CC. Management of eyelid
trauma. Aust N Z J Ophthalmol
1991;19:357-63.
Carroll RP. Management of eyelid
trauma. In: Hornblass A, editor. Oculoplastic
Orbital, and Reconstructive Surgery. Vol. 45.
Baltimore: Williams & Wilkins; 1988. p. 409-
14.

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