The treatment of eyelid lacerations depends on the depth and location of the injury. Detailed knowledge of eyelid anatomy is required to optimize repair and reduce the need for secondary repairs.
Lacerations not involving the eyelid margin
Superficial eyelid lacerations involving just the skin and orbicularis oculi muscle usually require only skin sutures, with or without buried subcutaneous sutures. Unnecessary scarring can be avoided by following the basic principles of repair, including conservative wound debridement, use of small-caliber sutures, wound edge eversion, and early suture removal.
The presence of orbital fat in the wound indicates that the orbital septum has been violated (Fig 11-1). Prior to repair, any foreign bodies in the wound should be identified and removed, and the wound should be properly irrigated. Orbital fat prolapse in the wound is also an indication for exploration of the levator muscle and aponeurosis. If lacerated, the levator muscle or aponeurosis must be carefully repaired to enable the levator muscle to function normally. Upper eyelid retraction and tethering to the superior orbital rim are common if the orbital septum is inadvertently incorporated into the repair. Similarly, orbital septum lacerations should not be sutured to avoid eyelid retraction from vertical shortening of the sutured orbital septum.
Lacerations involving the eyelid margin
Repair of eyelid margin lacerations requires precise suture placement and suture tension to minimize notching of the eyelid margin. Tarsal approximation and anatomical alignment of the eyelid margin should be meticulous in order to precisely repair the eyelid margin (Figs 11-2, 11-3). The eyelid margin is typically aligned by placing interrupted silk sutures through the lash line, meibomian gland plane, and the gray line. Additional nonmarginal tarsal sutures are placed through the height of the lacerated tarsus to strengthen the margin closure, as well as to avoid imbrication of the tarsal edges. To prevent corneal abrasion, the sutures should be partial thickness through the tarsus without extension through the conjunctival surface, and the suture tails should be directed away from the ocular surface. Eyelid margin closure should result in a moderate eversion of the well-approximated wound edges. Resorbable, buried, vertical mattress sutures may be used in the margin as an alternative to externally tied sutures.
Trauma involving the canthal soft tissue
Trauma to the medial or lateral canthal areas is usually the result of horizontal traction on the eyelid, which causes avulsion at the eyelid’s weakest points, the medial or lateral canthal tendon. Lacerations in the medial canthal area require evaluation of the lacrimal drainage apparatus, with canalicular involvement confirmed by inspection and gentle probing (Fig 11-4). These lacerations are discussed in more detail in Chapter 15 in this volume.
Figure 11-1 Left upper eyelid laceration not involving the margin shows orbital fat prolapse.
(Courtesy of Cat N. Burkat, MD.)
Figure 11-2 Eyelid margin repair. A, The eyelid margin is aligned with resorbable tarsus-to-tarsus sutures, and the lash line, gray line, and mucocutaneous junction are aligned with silk sutures. B, The tarsal sutures are tied and cut; the eyelid margin sutures are tied and left long. C, The skin surface of the eyelid is sewn closed, with the skin sutures used to tie down the tails of the margin sutures. D, An alternative approach is to place vertical mattress sutures in the lash line, gray line, and mucocutaneous junction, so that the knots are buried below the eyelid margin. This approach uses resorbable sutures that do not require removal.
(Parts A-C illustration by Christine Gralapp, part D illustration by Mark Miller.)
The integrity of the inferior and superior limbs of the medial or lateral canthal tendon can be assessed by grasping each eyelid with toothed forceps and tugging away from the injury while palpating the insertion of the tendon. Medial canthal tendon avulsion should be suspected when there is rounding of the medial canthal angle and acquired telecanthus. Treatment of medial canthal tendon avulsions depends on the extent of the avulsion. Attention to the posterior tendinous attachment to the posterior lacrimal crest is critical. If the upper or lower limb is avulsed but the posterior attachment of the tendon is intact, the avulsed limb may be sutured to its stump or to the periosteum overlying the anterior lacrimal crest. If the entire tendon, including the posterior portion, is avulsed but there is no naso-orbital fracture, the avulsed tendon may be wired through small drill holes in the ipsilateral posterior lacrimal crest. If the entire tendon is avulsed and there is a nasoorbital fracture, transnasal wiring or plating is necessary after fracture reduction. A Yshaped miniplate may be fixed anteriorly on the nasal bone, extending posteriorly into the orbit. The suture is sewn through the transected tendon and passed through holes in the miniplate. This technique is particularly helpful when the bone of the posterior lacrimal crest is absent.
Figure 11-3 Complex full-thickness eyelid margin laceration repair. A and B, Full-thickness eyelid laceration involving the margin. C, Intraoperative repair with silk sutures at the eyelid margin to minimize corneal irritation. D, Postoperative result at 3 months.
(Courtesy of Bobby S. Korn, MD, PhD.)
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.