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Eyelid lacerations

Eyelid lacerations
Literature review current through: Jan 2024.
This topic last updated: Jul 26, 2023.

INTRODUCTION — Proper management of eyelid lacerations requires thorough knowledge of the anatomy of the eyelids and periorbital structures, careful examination for associated ocular injury, and prompt referral to a subspecialist when complicated lacerations are encountered. (See 'Indications for surgical subspecialty consultation or referral' below.)

The evaluation and management of eyelid lacerations will be reviewed here. Closure of simple lacerations in other parts of the body is discussed separately. (See "Skin laceration repair with sutures".)

EPIDEMIOLOGY — Eyelid lacerations are an important subtype of facial trauma. In children, dog bites, handlebar injuries, and collisions with sharp objects while running (eg, sticks, thorns, retail display hooks, protruding nail) comprise the most common etiologies [1-3]. In adolescents and adults, blunt trauma (eg, motor vehicle collision, fist fight, eye gouging, ball sports) is most frequent [4]. Males are affected more commonly than females.

Ocular injury (eg, open globe, traumatic hyphema, corneal abrasion) may accompany eyelid laceration in up to two-thirds of cases; about one quarter of patients with open globe injures have associated eyelid or periorbital lacerations [5,6].

PERTINENT ANATOMY — Proper management and repair of eyelid lacerations requires a basic understanding of the anatomy of the eyelid and its surrounding structures (figure 1). The outermost layer of the eyelid is skin. Beneath skin is the orbicularis muscle, which closes the eyelid. Deep to the orbicularis is the orbital septum, which is a fibrous sheet that acts as an important barrier between the above-mentioned superficial preseptal tissues and the postseptal orbital anatomy. More posteriorly, orbital fat separates the orbital septum from the levator muscle which is the main retractor of the eyelid. The nearby Mueller's muscle also aids the levator in elevation of the eyelid. The conjunctiva lines the inner aspect of the eyelid and contacts the ocular surface.

The eyelid margin refers to the mucocutaneous junction of the eyelid. The anterior portion of the eyelid margin consists of skin and orbicularis muscle; the posterior portion of the eyelid margin consists of deep tarsus (a fibrovascular tissue that provides rigidity to the eyelids) and conjunctiva. The levator muscle inserts on the inferior, anterior edge of the tarsal plate, while Mueller's muscle attaches more superiorly along the upper margin of the tarsus.

The anatomy of the nasolacrimal system, also known as the tear drainage system, is an important consideration when evaluating a laceration of the periorbital tissues, especially when they involve the medial aspect of the eye (figure 2). Tears drain through two small openings on the medial aspect of the eyelids called puncta: one on each of the upper and lower eyelids. Tears pass through the upper and lower puncta and enter small tubular structures called canaliculi (one in each of the upper and lower eyelids). The upper and lower canaliculi join to form one common canaliculus which then drains into the lacrimal sac on the medial aspect of the orbit (lateral aspect of the nose). The lacrimal sac empties into the nasolacrimal duct which drains into the nose.

PRIMARY EVALUATION AND MANAGEMENT — The standard trauma evaluation should be followed to evaluate for life-threatening injuries in multiple trauma patients before attention is focused on the eye. (See "Trauma management: Approach to the unstable child" and "Initial management of trauma in adults".)

The key to appropriate care of eyelid lacerations is rapid recognition of other serious associated ocular injuries and differentiation of simple eyelid lacerations from complicated lacerations requiring surgical subspecialty evaluation and repair [7]. The clinician should have a high suspicion for an open globe injury or traumatic hyphema in any patient who has sustained an eyelid laceration. The clinical features and initial management of patients with these ocular injuries are summarized in the rapid overviews (table 1 and table 2) and are discussed in detail separately. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Initial emergency assessment and treatment' and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management", section on 'Approach'.).

Corneal abrasions and foreign bodies are also frequently associated with eyelid lacerations and are evaluated using slit lamp and fluorescein examination. However, the clinician should not place eye drops or fluorescein in the eye if an open globe is obvious or highly likely. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)

At times, the extent of damage to surrounding structures in a child with an eyelid laceration cannot be determined because the patient is unable to be cooperative with the examination. In these situations, if an open globe is likely, the child should have an eye shield placed and arrangements be made for examination by an ophthalmologist under procedural sedation in the emergency department or general anesthesia in the operating room.

Simple eyelid lacerations — The following precautions are essential before closing an eyelid laceration:

Do not initiate closure of an eyelid laceration prior to excluding injury to the globe. Pressure exerted on the eyelids and globe during wound closure can cause expulsion of intraocular contents if an open globe is present (table 1).

Have a low threshold to obtain computed tomography of the orbits if there is suspected open globe injury (eg, 360 degrees of subconjunctival hemorrhage), significant periorbital edema, marked ecchymosis, a projectile injury to the orbit, or a suspected orbital foreign body. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Clinical features' and "Open globe injuries: Emergency evaluation and initial management", section on 'Imaging'.)

Do not attempt to close complicated lid lacerations (eg, full-thickness lid lacerations, lacerations with orbital fat prolapse, suspected injury to the tear drainage system) prior to obtaining consultation with ophthalmology or plastic surgery. Permanent problems with scarring, eyelid malposition, and tearing could result. (See 'Indications for surgical subspecialty consultation or referral' below.)

Superficial, simple lacerations that are horizontal and follow the skin lines and that involve less than 25 percent of the lid will usually heal well without suturing [8,9]. The clinician may dress these with an antibiotic ointment (eg, Bacitracin). Alternatively, the clinician may apply an adhesive surgical tape (eg, Steri-strips or Leuko-strips) along the linear axis of the laceration or, in cooperative patients (eg, adolescents and adults), tissue adhesives [10]. If tissue adhesives are used on the eyelid, great care must be taken to assure that ocular exposure or gluing together of the eyelids does not occur. (See "Minor wound repair with tissue adhesives (cyanoacrylates)", section on 'Ocular exposure'.)

Uncomplicated lid lacerations of a greater extent are repaired with simple interrupted or running sutures placed in similar fashion as for other anatomic locations. Lacerations to the eyelid should be repaired within 24 hours of injury to prevent scarring and promote appropriate alignment of the eyelid tissues (see "Skin laceration repair with sutures"):

Prep and drape the operative area in a sterile fashion using Betadine.

Apply local anesthesia to the affected area. Provide procedural sedation to uncooperative patients (eg, young children).

Irrigate lacerations with normal saline, and carefully explore them prior to repair to delineate their full extent and to search for possible retained foreign bodies.

Close the laceration using either absorbable or permanent sutures, depending on personal preference. Acceptable suture choices for skin closure of eyelid lacerations include 6-0 or 7-0 nylon or prolene if permanent sutures are desired, or 6-0 fast absorbing plain gut if absorbable sutures are desired (eg, pediatric lacerations to avoid the need for suture removal). Care should be taken to avoid penetration of the underlying globe with the suture needle and to anatomically realign the wound edges with sufficient tension to appose the tissue and slightly evert the wound edges [7,11]. If the wound is deep, layered closure may be necessary. Deep layers can be closed with either 5-0 or 6-0 vicryl sutures. Wounds with protruding fat indicate that the orbital septum has been violated and warrant ophthalmologic consultation.

Provide tetanus prophylaxis as needed (table 3).

Arrange for wound recheck and suture removal (if nonabsorbable sutures placed) in five to seven days. Some experts suggest that for simple eyelid lacerations under low tension, suture removal may occur at three days.

Lid lacerations in children — Although most superficial lid wounds can be managed primarily by the emergency clinician, eyelid lacerations in children should be approached with particular care given that the clinical exam is often limited by patient cooperation. If trauma to the globe or complicated lid laceration is suspected, an ophthalmologist should be consulted to perform an exam under sedation or anesthesia [12].

Animal bites — Eyelid lacerations from animal bites cause a combination of lacerating and blunt injury to the affected tissue. Dog bites are most common and have a predisposition for injury to the medial aspect of the eyelids and the canalicular system [13]. Animal bites are often contaminated with polymicrobial pathogens from the animal's saliva, requiring thorough wound irrigation prior to closure, antibiotic prophylaxis, and careful monitoring for infection. Rabies prophylaxis should be considered if the attacking animal has signs of rabies or cannot be located. The management of animal bites is discussed in greater detail separately. (See "Animal bites (dogs, cats, and other mammals): Evaluation and management".)

INDICATIONS FOR SURGICAL SUBSPECIALTY CONSULTATION OR REFERRAL — The following injuries warrant care by an ophthalmologist or surgeon with special expertise in cosmetic repair of the eyelid (eg, plastic surgeon, oromaxillofacial surgeon):

Full-thickness lid lacerations — High suspicion for penetrating injury to the globe must be maintained in the setting of lacerations extending through the full-thickness of the eyelid. Subconjunctival hemorrhage, chemosis, or other changes to the ocular surface beneath a full-thickness laceration to the eyelid are particularly suggestive of possible trauma to the globe and merit urgent ophthalmologic evaluation.

Lacerations with orbital fat prolapse — The presence of fat in an eyelid laceration suggests that the orbital septum has been violated, allowing the underlying orbital fat to prolapse through the laceration (picture 1 and figure 1). Penetration of the orbital septum is a concerning finding in eyelid lacerations, since the laceration may have damaged the levator muscle, penetrated the orbital space, or both. Limitation of elevation of the upper eyelid confirms suspected damage to the levator muscle. Computed tomography of the orbit should be performed in the setting of fat prolapse to assess the extent of orbital injury, and surgical repair should be performed by a subspecialty service (eg, ophthalmology or plastic surgery) [11].

Lacerations through the lid margin — Repair of lacerations through the margin of the eyelid should also be deferred to a subspecialty service (picture 2). Meticulous realignment of the anatomic layers of the eyelid and the eyelid margin is essential in order to prevent scarring and notching of the eyelid margin [7].

Lacerations involving the tear drainage system — If not repaired appropriately, a lacerating injury to the tear drainage system can result in permanent tearing. Lacerations involving the medial aspect of the eyelids require particularly close inspection to exclude damage to the nasolacrimal system. The canaliculi are essential components of the tear drainage system of the eye, extending medially from the puncta on the nasal aspect of the upper and lower eyelids (figure 2). Thus, trauma to the canalicular system should be suspected when a laceration occurs medially to the punctum on the upper or lower eyelid. Definitive determination of canalicular involvement requires ophthalmologic consultation. The ophthalmologist may use special instruments to probe and irrigate the laceration in order to establish whether the laceration involves the tear drainage system. Lacerations involving the canaliculi require placement of silicone tubes to maintain patency of the drainage system while the laceration heals [1].

Orbital injury or foreign body — If the full extent and depth of an eyelid laceration cannot be determined, particularly in the setting of a puncture wound or when the history suggests projectile injury with a possible intraocular or intraorbital foreign body, computed tomography of the orbit and ophthalmologic consultation are warranted [14].

Laceration with poor alignment and/or avulsion — If the wound edges do not align well and/or tissue loss is suspected, repair of the laceration should be referred to a subspecialty surgery service (eg, ophthalmology or plastic surgery). Excessive tension on the wound margins after repair can lead to scarring and traction on the eyelid, causing malposition and distortion of the native lid anatomy.

OUTCOMES — If eyelid lacerations are repaired appropriately, most patients will achieve a successful cosmetic and functional outcome.

SUMMARY AND RECOMMENDATIONS

Pertinent anatomy – Proper management and repair of eyelid lacerations requires a basic understanding of the anatomy of the eyelid and its surrounding structures (figure 1). (See 'Pertinent anatomy' above.)

Evaluation for associated ocular injury – The clinician should have a high suspicion for an associated ocular injury (eg, open globe, traumatic hyphema, corneal abrasion) since these may accompany an eyelid laceration in up to two-thirds of cases. The clinical features and initial management of patients with these ocular injuries is summarized in the rapid overview tables (table 1 and table 2) and are discussed in detail separately. (See 'Epidemiology' above and 'Primary evaluation and management' above and "Open globe injuries: Emergency evaluation and initial management", section on 'Initial emergency assessment and treatment' and "Traumatic hyphema: Clinical features and diagnosis" and "Traumatic hyphema: Management", section on 'Approach'.)

Indications for surgical consultation – The following injuries warrant prompt consultation with an ophthalmologist or surgeon with special expertise in cosmetic repair of the eyelid (eg, plastic surgeon, oromaxillofacial surgeon) (see 'Indications for surgical subspecialty consultation or referral' above):

Suspected open globe or intraocular foreign body (table 1)

Laceration through the full-thickness of the eyelid

Lacerations with orbital fat prolapse (picture 1)

Lacerations through the lid margin (picture 2)

Lacerations involving the tear drainage system (figure 2)

Lacerations with poor alignment and/or avulsion

Management of simple eyelid lacerations – Once serious ocular injuries and complicated lacerations are excluded, superficial eyelid lacerations that comprise less than 25 percent of the lid may be managed with local wound care and healing by secondary intention alone. Uncomplicated lid lacerations of a greater extent are repaired with simple interrupted or running sutures (6-0 or 7-0 nonabsorbable nylon, prolene or 6-0 fast absorbing gut) placed in similar fashion as for other anatomic locations. Absorbable sutures are preferred for children. (See 'Simple eyelid lacerations' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Carolyn Kloek, MD, who contributed to an earlier version of this topic review.

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