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Chapter 18 EYELID and ADNEXAL INJURIES

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Chapter 18 EYELID and ADNEXAL INJURIES Eyelid and Adnexal Injuries Chapter 18 EYELID AND ADNEXAL INJURIES KIMBERLY PEELE COCKERHAM, MD* INTRODUCTION HISTORY, EXAMINATION, AND ANCILLARY TESTING SURGICAL MANAGEMENT OF EYELID LACERATIONS Anesthesia Preoperative Preparation Superficial Eyelid Lacerations Eyelid-Margin Involvement Levator Injury Complex Eyelid Injuries Total Avulsion SURGICAL MANAGEMENT OF ADNEXAL INJURIES Eyebrow Injuries Canalicular Injuries Medial Canthal Injuries Lateral Canthal Injuries Lacrimal Sac and Lacrimal Gland Injuries POSTOPERATIVE WOUND CARE SUMMARY *Director, Ophthalmic Plastics, Orbital Disease and Neuro-Ophthalmology, Allegheny General Hospital, 420 East North Avenue, Pittsburgh, Pennsylvania 15212; Assistant Professor, Department of Ophthalmology, Drexel University College of Medicine, Philadelphia, Pennsylvania 19102; formerly, Major, Medical Corps, US Army; Director, Neuro-Ophthalmology, Orbital Disease, and Plastic Reconstruction, Depart- ment of Ophthalmology, Walter Reed Army Medical Center, Washington, DC 291 Ophthalmic Care of the Combat Casualty INTRODUCTION Eyelid lacerations are a common emergency injuries are not considered true emergencies, and room challenge. The primary repair, which should in triage settings, life-threatening and actual sight- be the definitive surgery, is too often performed by threatening injuries (ie, open globes) should take medical students or physicians without ophthalmo- precedence. Eyelid lacerations can be closed up to logical training.1 Whether the setting is a civilian 72 hours after the injury without a great impact on emergency room or a battlefield, ophthalmologists functional or aesthetic outcome. Canalicular injury should be involved as early as possible. Inadequate can also be delayed (up to 48 hours), allowing the repair can lead to ocular irritation, pain, and even all-important primary closure to be performed by loss of the eye in cases of severe eyelid dysfunc- an experienced ophthalmologist. All tissue should tion. A complete eye examination is essential be- be preserved, and even obviously necrotic tissue or fore closing the wound to confirm the extent of in- detached tissue should be preserved until defini- jury—even if the wound appears deceptively tive closure is performed. Eyelid lacerations should simple. Fortunately, the eyelids are endowed with be irrigated with sterile saline whenever possible excellent blood supply, which allows direct closure and patched for transport. under tension and creation of large flaps without Future battlefield units may have tissue adhesive, the threat of necrosis.1–7 By following three main or glue, at their disposal. Closure with this tissue guidelines, ophthalmologists can maximize the glue appears to be a very time-efficient technique patient’s functional and cosmetic outcome: for laceration closure.8 When battlefield conditions prohibit access to needed equipment, many inno- 1. Perform careful anatomic repairs. vations are possible. A sterile safety pin can serve 2. Preserve the maximum possible amount of as a punctal dilator and probe, or 4-0 nylon can be tissue. used as a lacrimal stent. Independent of conditions, 3. Make liberal use of advancement flaps, trac- however, principles of closure and tissue preserva- tion sutures, and postoperative skin grafts. tion always apply. Irrigation, patience, and a prob- lem-solving outlook can often transform an omi- On the battlefield, eyelid lacerations and adnexal nous wound into an elegant functional closure. HISTORY, EXAMINATION, AND ANCILLARY TESTING A complete history of the wounding incident globe in cases of proptosis, chemosis, low intraocu- should be sought to determine the mechanism of lar pressure, and decreased vision. Repair of eyelid injury and assess whether foreign bodies (FBs) and adnexal injuries should be delayed if an open might be present. The timing is also important; in- globe is present or suspected. (The details of man- juries that occurred more than 24 hours before the agement of anterior and posterior segment trauma examination are at increased risk for infection and are addressed in Chapters 8–17 in this textbook.) poor wound healing. Fortunately, the eyelids are The lacrimal gland, canaliculi, and the lacrimal sac well vascularized and thereby defy infection even should be specifically inspected to determine if oc- with delayed closure. Most ophthalmologists pri- cult injuries have occurred. marily close eyelid lacerations up to 72 hours old; Examination of the eyelids and ocular adnexa canalicular lacerations are best repaired within 48 should include documentation of the intrapalpebral hours.5 The tetanus status of the patient should be fissure dimensions, levator function, and marginal addressed and appropriate antibiotic treatment ini- reflex distance to confirm symmetry of the eye- tiated immediately. lid appearance and function. The upper eyelid Before addressing the eyelid injuries, best-cor- should be gently everted to rule out FBs and to al- rected visual acuity must be documented, and a low inspection of the palpebral lobe of the lacrimal complete ocular examination should be performed gland. wherever possible. The status of the pupil should Dye disappearance time allows initial assessment be determined; the presence of anisocoria or an af- of lacrimal drainage integrity. Fluorescein strips or ferent pupillary defect should be quantitated. A 2% fluorescein dye solution (Fluoress) is placed in slitlamp examination of the anterior segment and the inferior cul-de-sac of both eyes. The dye should an indirect examination of the peripheral retina are drain into the canaliculi and then the lacrimal sac ideal. If in doubt, do no harm! Always suspect an open within 5 minutes. Delay in this process may indi- 292 Eyelid and Adnexal Injuries cate canalicular, lacrimal sac, lacrimal duct, or na- ography may be used as a screening tool to iden- sal injuries. If the dye disappearance is delayed, tify large, metallic FBs or prominent fractures. Ul- further testing is indicated. trasonography (A- and B-scans) is an effective tool Classic Jones I and II testing is rarely performed. for identifying intraocular or anterior orbital FBs Instead, the puncta are inspected and gently dilated. but is not helpful for imaging the posterior orbit. If the patient is awake and cooperative, the nasal Although computed tomography (CT) is excellent lacrimal system is irrigated with normal saline or at identifying and localizing most FBs, magnetic Alcaine, a topical anesthetic. If a canaliculus is resonance imaging (MRI) is superior at identifying crushed proximal to the common canaliculus, clear subtle nonmetallic FBs.10 However, if there is even irrigant will return with force from the puncta’s a remote chance that metallic FBs are present and being irrigated. If the canaliculi are blocked just could be mobilized and cause damage if subjected distal to the level of the common canaliculus, clear to MRI, then CT is the study of choice. irrigant will emerge from the opposite puncta. If a If midfacial trauma is present in the setting of canalicular laceration is present, irrigation may well eyelid and canalicular disruption, an otolaryngolo- up in the medial wound or emerge from the site of gist should be involved to assess the extent of na- disconnection.9 Techniques for identifying the dis- sal injury. If the maxilla is extensively damaged, tal end of a canalicular laceration are discussed be- then an oral surgery consultation is also essential low in this chapter. to allow simultaneous stabilization of the jaw. If a Further evaluation of the patient is essential if superior orbital fracture or cerebrospinal fluid leak an FB, fracture, or deep orbital trauma is suspected. is suspected, then neurosurgery consultation should In ER or battlefield circumstances, plain film radi- be sought before any ophthalmic intervention. SURGICAL MANAGEMENT OF EYELID LACERATIONS The surgical approach is determined by the ex- tion. In more extensive injuries, regional nerve tent of injury. Once a complete ocular survey has blocks may be additionally required. For regional confirmed that the globe is intact and that associ- anesthesia of lower lids, 1 mL of local anesthetic is ated orbital fractures are unlikely, the eyelid lac- injected into the infraorbital foramen located di- eration can be addressed. A thorough knowledge rectly inferiorly to the supraorbital notch, 1 cm be- of eyelid and ocular adnexal anatomy is essential low the infraorbital rim. Blocking the supraorbital, to avoid injury to vital structures and to maximize supratrochlear, or lacrimal nerves blocks sensation cosmetic outcome. It is important to keep in mind to the upper eyelid. that tissue loss always appears more substantial Alternatively, the frontal and lacrimal nerve may because of tissue edema and contraction. Even dra- be blocked by inserting a needle at the midpoint of matically disfigured eyelids can be repaired with the upper eyelid immediately below the orbital rim. careful reapproximation and knowledge of a few A small amount of anesthetic (0.5 mL) is injected reconstruction options.1–7,9 after the needle is advanced approximately 3 cm There are four major types of eyelid lacerations: along the orbital roof. The medial canthus and lac- rimal sac can be blocked by injecting the infra- 1. superficial, trochlear nerve, which lies immediately superior to 2. eyelid-margin involvement, the medial canthal tendon. In uncooperative adults 3. levator injury, and or children, general anesthesia is usually necessary. 4. complex tissue
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