Chapter 19 MANAGEMENT of EYELID BURNS

Management of Eyelid Burns

Chapter 19

MANAGEMENT OF EYELID BURNS

† JOHN D. NG, MD*; AND DAVID E. E. HOLCK, MD

INTRODUCTION

TYPES AND DEGREES OF EYELID BURNS

EYELID BURN INJURIES, HEALING, AND COMPLICATIONS First-Degree Burns Second-Degree Burns Third-Degree Burns Healing Process Complications of Eyelid Burns

EVALUATION AND TREATMENT OF EYELID BURNS 1st Echelon 2nd Echelon 3rd Echelon Evaluation and Treatment in the Continental United States

SUMMARY

*Assistant Professor of Ophthalmology, Division of Oculoplastics, Orbit, Lacrimal, and Reconstructive Surgery, Casey Eye Institute, Oregon Health and Sciences University, Portland, Oregon 97201; formerly, Lieutenant Colonel, Medical Corps, Flight Surgeon, US Army; Director, Oculoplastic, Orbital and Reconstructive Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Texas †Lieutenant Colonel, US Air Force, Medical Corps; Flight Surgeon; Director, Oculoplastic, Orbital and Reconstructive Surgery Service, Wilford Hall Medical Center, Lackland Air Force Base, Texas 78236-5300

307 Ophthalmic Care of the Combat Casualty

INTRODUCTION

Ocular and eyelid involvement in facial burns are much more extensive than the superficial skin in- common in both military and civilian settings. More jury. Therefore, a high index of suspicion for deep than two thirds of burns involving the face may injury is required, even in seemingly minor electri- include the eye or periocular area. Moreover, re- cal burns.11,12 views from major burn centers demonstrate that up Injuries from acids result in coagulative necro- to 15% of all patients treated for burn wounds have sis, which acts as a buffer against deeper tissue pen- burns involving the ocular and periocular region.1–4 etration. Alkali burns penetrate much deeper Most patients in civilian burn centers suffer flame because of tissue saponification and, hence, are as- burn injuries.3,4 Frequent ocular injuries seen as a sociated with greater injury. In the field environ- result of facial burns include lid burns, contracture ment, ionizing radiation injury may occur from ex- leading to ectropion (outward turning of the eye- posure to nuclear weapons or radioactive munitions. lids), and lagophthalmos (inability to close the eye- In most mild-to-moderate exposures, radiation burn lids), conjunctival burns, conjunctivitis, foreign damage is delayed until vasculopathy develops. bodies (FBs), corneal burns, abrasions, and perfo- Additionally, long-term, cancer-inducing effects rations. Because of the life-threatening nature of may result. severe burn injuries to the face and the associated The history of injury can provide vital clues re- massive swelling, ocular injuries may not be noticed garding the nature, extent, and initial therapy for early and treatment may be delayed.1,5–7 Appropri- the burn patient.9,10 Life-threatening systemic inju- ate early intervention can have a significant effect ries must be addressed before beginning eye care. on the final outcome for the burn patient. In the acute evaluation of facial, neck, and periocu- Burns to the eyelids may be caused by thermal lar burns, the medical caregiver must be keenly sus- (especially flame or flash burns), electrical, chemi- picious of a coexisting inhalational burn injury. In- cal, or ionizing radiation sources. The severity of haled toxic gases that are incomplete products of burns depends on the intensity of the burning agent combustion may directly damage the lower respi- (both the quantity of heat generated or transmitted ratory tract. Evidence of carbonized sputum in a by the burning agent, and the concentration and patient who otherwise appears well but who has amount of the burning agent), the duration of expo- had thermal exposure should alert the caregiver to sure, and the body’s response.2,8,9 Thermal injuries are the likelihood of significant airway injury. Airway the most frequent cause of ocular and periocular burn obstruction may worsen a few hours after presen- injuries. Liquid thermal burns vary in severity de- tation because of increasing airway edema. Inhaled pending on the substance. The temperature of non- hot air can damage the mucous membranes of the combustible liquids, like water, is usually less than mouth and upper respiratory tract. And burn in- 70°C on contact, and such liquids dissipate rapidly jury to the neck or chest may also contribute to res- from the initial contact area, thereby causing only su- piratory difficulty. perficial damage. On the other hand, the temperature On the battlefield, evaluation and treatment of of combustible liquids, like gasoline, at contact is usu- burns to the eyes and eyelids are tailored accord- ally greater than 100°C, and these liquids tend to be ing to the echelon level at which the injury occurs more viscous and may ignite clothing. Therefore, the and the medical expertise available. Appropriate damage is more localized but often deeper. Most in- securing of the airway may be lifesaving in the acute juries seen with flash burns involve the eyelids and stages before soft-tissue swelling has occurred. are superficial10 because of the ocular protective Careful monitoring of fluid replacement is manda- mechanisms: rapid reflex closure of the eyelids, tory in this period.7,8 Adherence to Advanced abrupt head movements, and elevation of the globe Trauma Life Support (ATLS) and Advanced Cardiac with eyelid closure (Bell’s phenomenon). Life Support (ACLS) protocols is critical.13 Tetanus Burns resulting from electrical injury are unique immunization status should be evaluated and because the underlying tissue destruction may be treated accordingly.7

TYPES AND DEGREES OF EYELID BURNS

Burns are usually categorized in two ways: by burn is any injury to the eyelid skin due to expo- etiology (type of burn) and by amount of tissue sure to heat, a caustic chemical, electricity, or ion- damage (degree of injury). Etiologically, an eyelid izing radiation. Eyelid burns due to thermal expo-

308 Management of Eyelid Burns

First Echelon

Soldier with Eyelid Burn

ATLS/ACLS Ye s Life-Threatening Injuries? No Chemical Injury? Evacuate

No Ye s

Protect eye with a firm Ye s Ruptured Globe? Copious irrigation cover or Fox shield Neutralize pH of lids and Evacuate eye Remove particles No

Cover with moist bandage May use eye antibiotic ointment Evacuate

Transport to next echelon

Second Echelon

Thermal Burn No Chemical Burn? Ye s Copious irrigation Neutralize pH of lids and eye Remove particles

Careful Exam: No Globe Involvement? Ocular status Eyelid status Ye s

Superficial/First-Degree Burn • Cool compresses Eye Chemical Burn • Lubrication (tears, ointment) Treatment according to • Pain control Globe chemical burn • Return to duty when better chapter

Partial-Thickness/Second-Degree Burn—Same as Superficial Burn • Antibiotic ointment for infection • Copious lubrication, moisture chamber or occlusion for drying • Suture or temporary tarsorraphy for corneal exposure • Trim eyelashes if singed and causing conjunctivitis • Evacuate to higher echelon

Full-Thickness/Third-Degree Burn—Same as Partial Thickness • Debride dead tissue and eschar • Protect eye with lubrication, occlusion, tarsorraphy • Evacuate to higher echelon

ATLS: Advanced Trauma Life Support (American College of Surgeons) ACLS: Advanced Cardiac Life Support (American Heart Association)

Fig. 19-1. Flow chart for acute management of eyelid burns.

309 Ophthalmic Care of the Combat Casualty sure are the most common and account for 96%8 of partial-thickness, and full-thickness burns.12 First- all burns. Thermal burns can occur from blast inju- degree (superficial) eyelid burns involve the epi- ries, incendiary munitions, or from direct exposure dermis only. Erythema and edema are characteris- to flames or hot liquids and gases. Typically, flash tic. The skin remains intact; however, there may be burns are more superficial than flame burns, be- some degree of skin shrinkage. A first-degree burn cause of the short exposure time common with flash can be likened to a mild-to-moderate sunburn (Fig- burns.8,9,13,14 ure 19-2). First-degree burns are self-limited and Chemical burns are usually caused by contact heal spontaneously. with an acid or alkali compound. A burn injury from Second-degree (partial-thickness) burns involve direct current may be caused by lightning strikes, the epidermis and part of the dermis. In second-de- whereas one from alternating current usually oc- gree burns, the skin often shrinks and blisters. The curs during contact with high voltage. Low-volt- blisters may break open, causing weeping and crust- age electrical exposure rarely causes a burn injury. ing of serous fluid. Open blisters with serous exudate Ionizing radiation burns may be secondary to thera- provide a significant opportunity for bacterial infec- peutic exposure, accidental exposure, or the use of tions. Second-degree burns are more painful than first- nuclear weapons. Except for high-dose exposure, degree burns because sensory nerve terminals have deep-tissue radiation burn damage is usually de- been injured and exposed (Figure 19-3). Second-delayed until radiation-induced vasculopathy devel- gree burns often heal spontaneously but with some ops 6 months to 2 years after exposure. On the other contracture and superficial scarring. hand, deep-tissue burn damage from chemical, elec- Third-degree (full-thickness) burns are the most trical, or thermal injury is immediate.9 serious. The epidermis is completely destroyed, and In the theater of operations, evaluation and treat- the injury involves the entire dermis and part or all ment of eyelid burns should focus on protecting the of the subcutaneous tissue. Charring and loss of eye by diagnosing the extent of damage, interven- skin characterize third-degree burns. The skin of- ing rapidly to prevent further damage to the eyes and eyelids, returning soldiers with mild injury to duty quickly, and stabilizing soldiers with more- serious eyelid damage for evacuation and definitive care (Figure 19-1). As with any other burn injury, eyelid burns are classified as first-, second-, or third-degree in severity. In 1994, however, to better describe their pathology, they were also classified as superficial,

Fig. 19-3. Second-degree eyelid burn of both upper eyelids. Injury involves epidermal loss and is more painful than a first-degree burn. Blisters and oozing of serous Fig. 19-2. First-degree eyelid burn. Note erythema and fluid may be present, and lid contraction may occur. Pho- mild edema of the upper eyelid along the pretarsal and tograph: Courtesy of Department of Ophthalmology, preseptal skin. There is no loss of epidermis, but there Wilford Hall Medical Center, Lackland Air Force Base, are areas of second-degree burns near the eyebrow. Tex.

310 Management of Eyelid Burns ten appears carbonized, white-brown, and waxy. The carbonized, dry eschar provides a nidus for infection and requires frequent debridement. Areas of third-degree burns are painless because of damage to sensory nerves; however, tissue surrounding the burn may be painful due to lesser degrees of burn injury. Third-degree burns of the eyelids usually imply full-thickness injury, as the lids are approximately 2 mm thick and have very little subcutaneous tissue (Figure 19-4). Lids with severe second-degree and third-degree burns are commonly accompanied Fig. 19-4. Third-degree eyelid burn of the right upper by significant burn injury to the surrounding tis- eyelid. Injury involves full-thickness skin. Charring and white-brown waxy consistency is often present. Third- sues, including the face, forehead, scalp, ears, degree burns usually are not painful. Tissue is damaged, mouth, neck, and torso. This involvement implies and contraction and lagophthalmos are usually present. a high risk for life-threatening injuries and damage Photograph: Courtesy of Department of Ophthalmology, to the most common sources for skin grafts for eye- Wilford Hall Medical Center, Lackland Air Force Base, lid reconstruction. Tex.

EYELID BURN INJURIES, HEALING, AND COMPLICATIONS

When tissue is exposed to a burn injury, the area logically, superficial burns only involve epidermal of injury often resembles a bull’s-eye target, with layers. Healing occurs in 3 to 7 days, accompanied the severity of injury decreasing from the center to by superficial peeling. There is no scar formation the periphery. In a third-degree burn, the central although discoloration may develop. area is the zone of coagulation, where tissue is destroyed and no longer viable, hence its characteris- Second-Degree Burns tic white, leathery appearance. The area just peripheral to the center is the zone Mild (superficial) partial-thickness burns are of stasis, which temporarily has decreased vascular- commonly caused by immersion scalds of short ity but can recover barring further injury. The zone of exposure. The wounds blister, weep, and form moist stasis can be divided into a superficial zone and a blebs. There is intense erythema, significant pain, deeper zone. The superficial zone demonstrates early and temperature sensitivity. Histologically, epider- stasis because it sustains greater injury and becomes mis and some papillary dermis are involved. Heal- ischemic within 2 hours, owing to vasoconstriction ing occurs within 7 to 21 days without grafting and and platelet aggregation with thrombosis. The deeper with little or no scarring. Pigmentary changes, how- zone shows delayed stasis with ischemia beginning ever, are common. between 4 to 24 hours after the injury. If cared for Moderate (deeper) partial-thickness burns are properly, hair follicle epithelial cells remain viable commonly caused by immersion scalds of longer and will repopulate and migrate. duration and flame injury. Blisters are large and The third and most peripheral area is the zone of thick-walled; they increase in size. The skin appears hyperemia. Vascular structures remain intact and the mottled white and pink to cherry-red. Histologically, area blanches on pressure. There is no cell death, the epidermis, papillary dermis, and reticular dermis only edema and erythema.11 Second-degree burns are involved. Some subcutaneous involvement may do not have a zone of coagulation but do have vary- occur. Healing occurs in 21 to 35 days in uncompli- ing degrees of zones of stasis and hyperemia. First- cated cases. If infection or reinjury occurs, the degree burns demonstrate zones of hyperemia only. wound may convert to a full-thickness injury. Severe partial-thickness burns have a propensity First-Degree Burns to develop hypertrophic scars and to convert to full- thickness injuries. Superficial burns are commonly caused by sunburn, ultraviolet ray exposure, and short-duration Third-Degree Burns flash burns. They are dry burns with edema and no blistering. Erythema and pain are common. Histo- Full-thickness burns are usually caused by

311 Ophthalmic Care of the Combat Casualty chemical, electrical, flame, and scald injuries. The is crucial for visual clarity. The lacrimal drainage skin appears dry, leathery, nonpliable, and there system begins in the eyelids as the lacrimal puncta may be charring, eschar, and significant avascularity. and continues as the canaliculi, lacrimal sac, and There is little or no pain; the hair in the affected area the lacrimal duct, which empties beneath the infe- pulls out easily. Histologically, the wound includes rior turbinate in the nose. The lids act as a lacrimal the subcutaneous tissue and may include fascia, pump to remove the tears from the ocular surface muscle, tendon, and bone. In a small lesion, healing and drain them into the nose. Burn injuries to the from the leading edge of the wound may occur over eyelids can compromise one or all of these func- several weeks. In larger lesions, grafting is neces- tions and cause visual debilitation. sary; otherwise, healing takes many months.12 Eyelids that cannot close put the soldier at risk of sustaining corneal FBs, abrasions, and ulcers that Healing Process cause significant pain, impairment, and possible loss of the eye. Eyelids that cannot open because of Reepithelialization of wounds occurs from epi- burns may leave the soldier essentially blind and thelium located at wound edges and skin append- ineffective in the battlefield. A blinded soldier also ages, such as hair follicles, sebaceous glands, sweat requires the help and time of another soldier to as- glands, and their ducts. For large areas, granula- sist him or her to safety. tion tissue must first bridge the wound before An injured or scarred lacrimal drainage system epithelialization can occur. Contraction occurs in anywhere along its length may cause epiphora (a second- and third-degree wounds and aids in re- wet, tearing eye due to abnormal drainage of tears), storing epithelial continuity; however, contraction which interferes with visual clarity. An abnormal often distorts the functioning of the eyelids.15 tear pump mechanism can also leave the soldier with epiphora. Complications of Eyelid Burns Therefore, treatment of eyelid burns is a vital component in caring for warfare injuries. Effective The eyelids serve several functions. They pro- treatment of minor injuries allows the soldier to tract, or close, to protect the eye from wind-borne return to duty with minimal delay. Significant eye- dirt and debris and the drying effects of the envi- lid burns, which are likely to develop any or all of ronment. The eyelids retract, or open, to provide these complications, require proper evaluation and an unimpeded visual axis for seeing. The eyelids management to protect the eye and limit damage contain glands that secrete the aqueous (accessory to injured structures. Early evacuation of severely glands of Krause and Wolfring) and lipid (mei- burned patients is required to minimize consump- bomian glands) portions of tears. They also blink tion of resources in the theater of operations and to to spread the tear film evenly over the eye, which maintain the best prognosis possible for the soldier.

EVALUATION AND TREATMENT OF EYELID BURNS

Casualties with eyelid burns often have concomi- jury. If sterile water or saline is not available, then tant facial, neck, and upper torso burns (see Figure any neutral, relatively clean liquid will suffice un- 19-1). Airway compromise should always be con- til sterile solutions are available. Particulate matter sidered. Therefore, immediate evaluation and must be gently rinsed out because it may contain treatment should follow the ATLS16 and ACLS17 chemical reagents and cause further damage. protocols. Once copiously irrigated and debrided of foreign material, the lids should be covered with a moist 1st Echelon bandage, if possible. First-degree burns may need only to be rinsed clean. Bandaging for second- or If a casualty might have a chemical burn to the third-degree burns is desirable, if available.1,2,13,14 eyes, then the eyes and eyelids should be thor- Antibiotic eye ointment (eg, bacitracin, gentamycin) oughly rinsed with sterile water or saline. Rapidly may be used with bandaging. If neither ointment irrigating the offending chemical and returning the nor bandage is available, the wound should be kept ocular tear film pH to normal can significantly de- moist to decrease tissue necrosis and eschar forma- crease morbidity and improve visual outcome. The tion. Desiccation of a burn wound can increase is- rinse may require several liters of fluid and should chemia in the zones of stasis where partial vascular be done as soon as possible after the chemical in- compromise exists.12

312 Management of Eyelid Burns

If an open globe injury is suspected, then bandaging of lid burns is contraindicated and a protective shield should be placed over the orbital rim to prevent pressure on the eye (Figure 19-5). Direct pressure on an open globe will increase the ocular injury, may expel intraocular contents, and can cause irreversible damage to an otherwise salvage- able eye.

2nd Echelon

If a chemical burn is suspected, the eyes should be copiously flushed with normal saline solution to remove any residual chemicals and particulate matter, and treatment should be initiated as described in Chapter 7, Chemical Injuries of the Eye. Additionally, the eyelids and periocular tissue should be rinsed of all chemicals in a similar man- ner. The remainder of the evaluation is the same as for radiation, electrical, and thermal burns13 (described below).

Evaluation of the Eyes

The initial 2nd-echelon evaluation determines the status of the eyes. The ocular examination must Fig. 19-5. Eye shields. A Fox shield (left) and a modified be performed as soon as possible, because the eye- disposable cup (right). Either may be used to protect the lids often swell shut after an eyelid burn injury. potentially ruptured eye from direct pressure. The shield Swollen eyelids and pain associated with first- and or cup is placed over the eye with the rim of the shield second-degree burns often render a delayed exami- resting on the bony prominence of the orbital rim. No nation extremely difficult and possibly hazardous pressure should be placed on the eyelids or eye itself. to the injured eye. A complete history is needed to The shield is secured in place with a piece of tape. direct the examination and to determine chronic management. The mechanism of injury should be and Wolfring, the mucosal goblet cells, the lipid- elicited. Specifically, was the burn due to a blast producing tarsal meibomian glands, and the ducts injury or to thermal, chemical, electrical, or radia- of the main aqueous-producing lacrimal gland. A tion exposure? dry eye is at significant risk of ulceration and per- Initial Visual Acuity. Visual acuity is measured foration, especially if the eyelids are damaged and with a standard eye chart or near-vision acuity card. incapable of protecting the ocular surface. Deepi- If these are not available, any reading material may thelialization of both the palpebral (lid) conjunc- be used. The vision must be clearly documented for tiva and the bulbar (ocular) conjunctiva can cause baseline examinations. If an eye chart is not avail- symblepharon formation (scarring between these able, it is sufficient to describe that the patient was two surfaces). Immobile eyelids and a tethered able to read fine or large print at reading distance. If globe may result. the patient cannot see clearly enough to read, the ex- Status of the Cornea. The examiner should check aminer should determine if he or she can count fin- for lacerations, abrasions, and burn injuries to the gers, see hand motion, or detect light in that order. cornea and sclera. Corneal and scleral lacerations Any measurement should be accurately recorded. must be emergently repaired. Corneal abrasions Status of the Conjunctiva (Ocular Mucous must be treated with lubrication and topical antibi- Membranes). The examiner should check for lac- otics to prevent infection and ulceration that can erations or loss of mucosal surface from blast or lead to perforation. Ischemia due to coagulation of burn injury. Injury to the conjunctiva can cause a limbal vessels can lead to corneal breakdown. If is- dry eye due to damage to the tear-producing glands: chemia is noted, the examiner should follow the the accessory aqueous-producing glands of Krause protocol in the corneal burn section.

313 Ophthalmic Care of the Combat Casualty

Anterior Chamber. The examiner should check burned tissue can be deceiving; the extent of dam- for a collapsed chamber or hyphema, which can age tends to delineate itself over the next several indicate an open globe or significant blunt trauma days. Specifically, severe partial-thickness burns from a blast injury. Hyphema may lead to increased must be aggressively cared for to limit damage and intraocular pressure, traumatic glaucoma, and cor- prevent progression to full-thickness injury due to neal blood staining, which can cause significant progressive ischemia. The life- and sight-threaten- ocular morbidity. ing burn wound complication that medical officers Shape of the Eye. In difficult cases in which the must vigilantly guard against is bacterial infections; ocular examination is severely limited because of the organisms most commonly implicated in burn other severe injuries, the examiner should deter- infections include Streptococcus, Staphylococcus, mine if gross eye deformity is present to rule out a Pseudomonas, and Proteus species, and Escherichia ruptured globe. Ruptured globes should be imme- coli. Burn wounds should be kept clean and moist. diately referred for surgical treatment. If an open Dry eschar increases the likelihood of secondary globe injury is suspected, treatment should follow infection. The examiner must also be alert to sev- the protocol for penetrating injuries. In the interim, eral signs that may indicate other impending com- the eye should be protected with an eye shield (see plications (Table 19-1). Figure 19-5). Initial 2nd-echelon treatment involves removing any residual chemicals or foreign bodies, as Evaluation and Treatment of the Eyelids described above, and protection of the eye and eyelids. Burn injuries to the eyelids are often com- Once the eyes have been examined and treated plicated by decreased tear production from dam- accordingly, the eyelids should be examined. The age to lacrimal, conjunctival, and eyelid glands, extent and degree of the eyelid burns are deter- all of which contribute to tear production (Figure mined, and facial burns adjacent to the eyelids must 19-6). As previously mentioned, decreased tearing be noted as well, because contraction of tissue can increases the risk of corneal drying, abrasions, be transmitted to the eyelids, causing restriction and ulcers, and perforations. Additionally, the burn- decreased function. The initial appearance of injured eyelid is often less mobile and may not

TABLE 19-1 EYELID BURNS: SIGNS OF POSSIBLE COMPLICATIONS

Sign Observed Possible Complication

Loss of eyelid tissue, causing exposure of the Tissue loss requires immediate attention and protection of the eye. eye and cornea (exposure keratopathy) Shrinkage of eyelid tissue with lagophthalmos, Mild lagophthalmos in an alert patient may be asymptomatic, but causing exposure of the eye burn injuries in an unconscious patient can remove the eye’s protective mechanisms (eg, tear production, blink reflex, Bell’s phenomenon, and corneal tactile sensitivity) and place the eye in jeopardy. Mild symptoms of exposure can be treated with lubricating drops and ointment. More severe lagophthalmos requires aggressive lubrication and ocular surface protection. In the obtunded patient, even mild lagophthalmos can be devastat- ing because the patient’s blink reflex is absent, and there is suppression of the Bell’s phenomenon. Loss of Bell’s phenomenon increases the risk of corneal drying of the exposed surface. Loss of eyebrows or lashes in an otherwise Finding suggests thermal damage, which may result in delayed normal-looking eyelid complications of lid contraction, tissue loss, and corneal exposure. Patients with singed lashes should be observed over the first week to check for delayed effects of thermal damage. These patients may also complain of foreign body sensation, which may be due to lash particles falling onto the ocular surface.

314 Management of Eyelid Burns

Main lacrimal gland or her eyelids and see, he or she may be returned to Meibomian glands duty. Second- and third-degree burns should be treated similarly to first-degree burns, but they are at greater risk of Gram-negative bacterial infections. Application of gentamycin or tobramycin ointment may be indicated. However, care must be taken to watch for a toxic keratopathy (seen as diffuse staining of the cornea with fluorescein stain under a cobalt-blue light), which may develop with prolonged use of gentamycin and tobramycin. For deeper wounds, wet to dry physiological saline dressings should be used and systemic antibiotics initiated if infection is suspected. The saline dressings are used = Goblet cells to decrease formation of dry coagulum (scabbing), = Accessory lacrimal glands which is a nidus for infection, and to decrease progression of ischemia in the zone of stasis.13,18,19 Fig. 19-6. Tear production system. The diagram shows Eyelids with second- and third-degree burns of- the glands responsible for production of the aqueous and ten contract and cause some lagophthalmos, and if sebaceous components of tears. Any or all of these glands that happens, the soldier should be evacuated to can be damaged by thermal, electrical, chemical, or ra- the 3rd echelon for medical care. If significant ex- diation burns. Drawing: Courtesy of Department of posure of the cornea is evident or if there is lagoph- Medical Illustrations, Brooke Army Medical Center, Fort thalmos with corneal drying and an epithelial de- Sam Houston, Tex. fect, aggressive treatment is required to prevent corneal ulceration or perforation. The first line of treatment is frequent application of ophthalmic protect the eye sufficiently. Debris in the battlefield antibiotic ointment (at least six times daily). If anti- can further increase the risk of secondary ocular biotic ointment is not available, then a nonmedi- injury. cated lubricating ophthalmic ointment (eg, Refresh Treatment at the 2nd echelon also depends on the PM, mfg by Allergan, Inc, Irvine, Calif) or even soft, type and extent of the burn, and the anatomical moist saline dressings can be used. structures affected. Chemical injuries should be ir- If ointment alone is not effective or if there is in- rigated copiously (at least 2 L) with normal saline sufficient staffing to maintain that regimen, then a or water. The pH of the injured eye should be moisture chamber or cellophane occlusion should checked using pH testing strips to ensure that ocu- be placed over the antibiotic-ointment-lubricated lar surface neutrality is attained. When neutral, the eye (Figure 19-7). The moisture chamber—acting patient should be rechecked periodically to verify like a greenhouse—keeps the moisture from evapo- that no continual damage is occurring by missed rating from the surface of the eye. The chamber and particles or chemicals. the cellophane also keep out foreign material and Mild first-degree burns with no eyelid contrac- help maintain a more physiological local tempera- tion or corneal exposure may be treated with topi- ture. Patients with significant facial and head burns cal ophthalmic antibiotic ointment (eg, erythromy- may not tolerate moisture chambers, and if there is cin) and cool compresses. Artificial tears may be periocular skin loss or excessive weeping of serous helpful for mild ocular irritation. Assuming no fluid, a bubble chamber may not stay in place. In other injuries, the soldier may be returned to duty. these settings, the cellophane patch may be the best The soldier should be informed of the possibility alternative. that a mild second-degree burn might manifest it- If the moisture chamber is not available or is in- self in a few days, and that mild pigmentary effective, a temporary tarsorrhaphy suture should changes of the skin might also occur. be placed (Figure 19-8). A suture tarsorrhaphy is Significant first-degree burns that cause the eye- created by passing a double-armed 5-0 suture lids to swell and droop over the pupils (a mechanical though a bolster (small piece of foam, rubber, or ptosis) may require several days of cool compresses, plastic) and through the lower lid just inferior to pain control, and topical antibiotic or lubricating the lashes. The needles are passed out through the ophthalmic ointment. Once the soldier can open his lower-lid gray line and into the upper-lid gray line.

315 Ophthalmic Care of the Combat Casualty

a b

Fig. 19-7. Occlusive moisture dressings. (a) A moisture chamber (mfg by Wilson Ophthalmic Corp, Mustang, Okla). (b) A cellophane occlusive dressing. Both types of dressing require frequent application of lubricating ointment and act like greenhouses to keep the eye surface moisturized.

The sutures are then passed out the upper-lid skin If singed lashes are present, consider cutting the above the lashes and through another bolster be- lashes with scissors coated with antibiotic ointment. fore the suture ends are tied. The sutures may be This will prevent debris from falling into the con- tied in a bow to facilitate periodic examinations of junctival cul-de-sac and irritating the cornea and the ocular surface. The bolster reduces the incidence mucous membranes.18,19 of sutures “cheesewiring,” or cutting through, the eyelid tissues. 3rd Echelon It is important to realize that suture tarsorrhaphy is a temporary measure and will not prevent A patient with eyelid burns should be evaluated cicatricial changes to the eyelid. Additionally, a su- by an ophthalmologist at the 3rd echelon. By this ture tarsorrhaphy may be associated with eyelid time, any acid or alkali burn should have been di- margin irregularities. In severe contracture, the lids agnosed and acutely treated, otherwise severe pro- may pull through the tarsorrhaphy suture, which gressive damage would have occurred. In-depth results in a cheesewire laceration of the eyelid. Sur- examination of the eye and periocular structures is gical marginal tarsorrhaphies are not often used essential. Ocular injuries must always be ruled out because the lid margin anatomy is destroyed, mak- first. Definitive subacute and chronic eyelid treat- ing reconstruction more difficult. ment is then provided.5

Fig. 19-8. Suture tarsorrhaphy. A double- armed 4-0 suture (silk, nylon, or Vicryl) is passed through a foam or rubber bolster (cut from a surgical drain) and through the eyelid skin 4 mm inferior to the eyelashes. The sutures exit the lower lid through the gray line (middle portion of the lid margin). Both ends are then passed through the gray line of the upper lid and out through the skin about 4 mm above the upper lash line. The sutures are passed through another bolster and tied securely to pull the eyelids closed. Several such sutures may be placed along the length of the lid to achieve maximum corneal protection. The bolster reduces the risk of the suture cheesewiring through the injured eyelid tissue. Caution is necessary to avoid suture contact with the globe. Drawing: Courtesy of Department of Medical Illustrations, Brooke Army Medical Center, Fort Sam Houston, Tex.

316 Management of Eyelid Burns

Evaluation are examined for damage to the meibomian glands, puncta, and canaliculi. The conjunctiva is examined The components of the 3rd-echelon eye and eye- for lacerations and abrasions that can signal a pen- lid examination are similar to but more extensive etrating globe injury or potential symblepharon than those of the eye and periocular examination formation (contracted conjunctival scarring be- at the 2nd echelon. Examinations at the 3rd echelon tween the eyelid and eyeball conjunctiva). The cor- are conducted by medical officers, some of whom nea is also examined for lacerations, abrasions, may be trained and certified ophthalmologists. limbal ischemia (seen as a white, noninjected bor- Visual Acuity. Best corrected visual acuity der between the sclera and cornea), and FBs. The should be obtained and, if abnormal, correlated anterior chamber is examined for FBs, hyphema with clinical findings to explain the deficit. Results (blood in the anterior chamber), angle recession should be compared to the initial visual acuity to (seen as a deeper than normal anterior chamber determine prognosis and course of the injury. De- angle between the iris root and the cornea), and increased visual acuity can be due to multiple etiolo- flammation (seen as haziness in the anterior cham- gies, including lid deformities, dry eyes, epiphora, ber). Significant anterior chamber “flare” out of corneal irregularities and scars, anterior chamber proportion to anterior chamber “cell” may signal hyphema or inflammation, iris damage, cataract, ischemia (“flare” and “cell” pertain to the grada- vitreous hemorrhage, retinal injuries, and optic tion of anterior chamber inflammation). The iris is nerve injuries. examined for sphincter tears or lacerations. The lens Pupil Examination. The pupil examination is is examined for dislocation, subluxation, or trau- performed to determine if significant blunt trauma matic or ischemic cataract. or blast injury may have damaged the anterior vi- Eyelashes. Singed lashes and eyebrow hairs may sual pathway, as an afferent pupillary defect (APD) indicate thermal damage, which may manifest or Marcus-Gunn pupil would suggest. APD is de- itself over several days. Therefore, patients tected by having the patient focus on an object in with singed lashes should be observed. If an FB the distance to prevent accommodative miosis (pu- sensation is due to lash particles on the eye, the pil constriction at near). In a darkened environment, lashes should be trimmed and lubricated with oint- a penlight is shined directly through the pupil of ment. one eye, and the pupil constriction is observed. The Eyelids. The degree and extent of burns must be light is then immediately shined in the opposite eye, determined to evaluate globe coverage, motility, and pupil constriction is observed. If one pupil con- lagophthalmos (amount of exposure on eyelid clo- stricts more sluggishly than the other, does not con- sure), ectropion (outward turning of the eyelid strict at all, or actually dilates when the light is margin), entropion (inward turning of the eyelid brought from the opposite eye, then the more-slug- margin, often with lashes rubbing against the cor- gish pupil is abnormal and is determined to have nea). Children have thin skin and, therefore, expe- an APD. Anisocoria (asymmetrical pupils) can be rience greater depth of burn with increased scar- due to a variety of causes including trauma to the ring and disfigurement.20 iris root, iris sphincter damage, or iris ischemia due Face. Look for adjacent burns, which may con- to thermal-induced hypovascularity. Intracranial tract and pull on the eyelids causing ectropion, reinjury may also cause anisocoria from a third–cra- traction or lagophthalmos, and exposure kera- nial nerve palsy. topathy. Also, note whether the usual donor sites Ocular and Lid Motility. The eyes should be ex- for skin graft (upper eyelids and retroauricular, amined carefully for motility to rule out orbital or periclavicular, and inner arm areas) are involved. neurological injury. The lid motility is examined as Intraocular Pressure. Monitor intraocular pres- well to determine whether there is mechanical or sure (IOP) for elevation or hypotony. Elevated IOP neurological dysfunction due to burn or blast in- may indicate traumatic glaucoma due to anterior jury. For example, a ptotic lid with poor mobility chamber angle injury or traumatic cataract. Low can be caused by mechanical restriction from lid IOP may signal occult globe rupture, choroidal or edema or burn scarring, or it could be due to a third- retinal detachment, or anterior segment ischemia. nerve palsy stemming from increased intracranial Posterior Segment (Fundus) Examination. The pressure from a related head injury. posterior segment should be evaluated for inflam- Complete Slitlamp Examination. A thorough mation, FBs, retinal detachment, chorioretinal in- slitlamp examination is performed. Eyelid margins juries, and optic nerve injuries.

317 Ophthalmic Care of the Combat Casualty

Treatment The cellophane occlusive dressing can be made by cutting a square of cellophane wrap to a size that Treatment at the 3rd echelon should include co- will completely cover an eye and reach the orbital pious irrigation of chemical burns if this was not rims on all sides. The cellophane is kept in place by adequately done at lower echelons. Examine the the adhesive effect of the topical eye ointment. This eyes and remove any remaining chemical particles dressing has the advantage of not irritating the pe- from the conjunctiva and eyelids. Then, proceed riocular skin because there is no glue adhesive. It according to the protocol for chemical ocular inju- also avoids pressure irritation because it has no elas- ries (Chapter 7, Chemical Injuries of the Eye). Once tic band. The cellophane dressing stays in place stable, the eyelids should be treated as indicated in even if the patient moves in bed. If the lids are com- the sections that follow. pletely missing, it allows the patient to have some First-Degree Burns. Because first-degree burns vision while providing barrier protection. are self-limited and heal well, these superficial The temporary suture tarsorrhaphy may be nec- burns are seen at the 3rd echelon only because the essary if excessive lagophthalmos allows significant patient has other injuries. Treatment includes ap- corneal drying. The tarsorrhaphy temporarily sews plying cool compresses and providing analgesics the eyelids closed (see 2nd-Echelon Treatment, as needed. Occasionally mild, transient lagophthal- above). mos and corneal exposure occur and are treated If the lacrimal system is involved, nasolacrimal with artificial tears and ointment for lubrication. system intubation with silicone tubing should be More-severe exposure in an obtunded patient considered to prevent cicatrization and future na- may require a moisture chamber (see Figure 19-7). solacrimal system obstruction and epiphora (Fig- Numerous moisture chambers are commercially ures 19-9 and 19-10). The tubing is left in place for available. Some are self-adhesive and are applied 3 to 9 months, until the cicatrizing changes of the much like an elastic bandage. However, the adhe- lid have stopped, or until the patient is unable to sive irritates some patients’ skin, and, if the perio- tolerate the tubes once initial healing has occurred. cular area is lubricated for adjacent burns, this type If well tolerated, the silicone stents may be left in of moisture chamber does not stay in place well. longer, keeping in mind that burn-scar remodeling Another common type of moisture chamber has continues even past the 1-year mark. Monocana- an elastic band and is worn like a pirate patch. This licular intubation may be more beneficial than a system works well if an adhesive chamber irritates bicanalicular tube, as the bicanalicular tube may the skin or if periocular lubrication is present. The cause cheesewiring of the canaliculi as the lid tis- drawbacks to the pirate patch moisture chamber are sue contracts and places excess traction on the that the elastic can irritate injured scalp and head canaliculi. skin and when patients turn in their sleep, they can Third-Degree Burns. Aggressive treatment is dislodge the patch. More commonly, patients have warranted for third-degree, or full-thickness, burns a mechanical ptosis due to lid edema rather than of the eyelids. Frequent lubrication is essential. Se- lagophthalmos. Mechanical ptosis actually protects vere cicatrizing ectropion with unresponsive cor- the eye from exposure, especially in unconscious neal drying should undergo surgical relaxing inci- patients. sions of the burn scars (Figure 19-11). When the lids Second-Degree Burns. Cicatricial changes usu- are significantly immobilized because of contrac- ally accompany second-degree or partial-thickness tion, the skin and underlying scar tissue must be burns. If the patient is awake, corneal and conjunc- sharply transected to allow the lids to protract over tival exposure and drying should be treated with the globe. artificial tears. Ophthalmic lubricants or an oph- If a temporary suture tarsorrhaphy does not hold, thalmic antibiotic ointment (if a corneal epithelial then Frost sutures should be placed to keep the lids defect is present) should be used six or more times closed and on traction (Figure 19-12). A Frost su- per day for an unconscious patient. If drying is se- ture is created much like a suture tarsorrhaphy. Both vere, the following measures should be considered: ends of a double-armed suture are passed through a bolster and through the lid like a tarsorrhaphy • moisture chambers over the eyes; suture. However, instead of passing them through • cellophane, ocular-occlusive dressings (ap- the opposite lid, the trailing ends are taped to the plied six times per day); and forehead (for the lower lid) or to the cheek (for the •temporary suture tarsorrhaphies (see Fig- upper lid). Again, caution is needed to verify (1) ures 19-7 and 19-8). that the suture is correctly passed through the tar-

318 Management of Eyelid Burns

Fig. 19-9. Silicone stents. Shown are two types of silicone stents, which may be passed through the nasolacrimal system to prevent cicatricial closure and obstruction. A Guibor tube (top) may be retrieved with a grooved director. A Crawford tube with an olive-tipped introducer (bottom) is retrieved by a Crawford hook (similar to a Fig. 19-10. Intubating the nasolacrimal system. The fig- small crochet hook). ures show passage of the silicone stents through the vertical and horizontal canaliculi into the nasolacrimal sac and down into the nose through the nasolacrimal duct (a closed loop). The tube is retrieved below the inferior turbinate with a Crawford hook.

a b

Fig. 19-11. Relaxing incision. The cicatrix (a) of the lower eyelid (b) is incised with a scalpel blade to release the retraction and ectropion.

Fig. 19-12. A Frost suture is used to put the eyelid on traction, prevent recurrence of retraction, and to allow the eyelid to cover the eye. A Frost suture is placed by passing a double-armed suture (4-0) through the wound and out through the lower eyelid gray line. The suture is pulled up and secured to the forehead with benzoin and plastic tape.

319 Ophthalmic Care of the Combat Casualty

junctiva and tarsus approximately 4 mm above the lid margin. Vertical incisions are made in the conjunctiva and Müller’s muscle. The pedicle is then undermined in a plane between Müller’s muscle and the levator aponeurosis. Once this is accomplished, the lower lid is horizontally incised on the mucosal side about 2 mm below the lid margin in a length corresponding to that of the upper-lid pedicle flap. The tarsoconjunctival flap from the upper lid is sewn into the lower-lid incision using 6-0 Vicryl (polyglactin) suture. The non-margin-sharing tarsorrhaphy provides excellent globe coverage in patients with lagophthalmos from significant eyelid burns. This procedure does not distort the lid margin and is created Fig. 19-13. A non-margin-sharing tarsorrhaphy preserves the integrity of the eyelid margin. A scalpel blade is used from posterior lamellar lid tissue, which is less of- to incise the upper eyelid conjunctiva and the superior 4 ten involved in burn injuries. Therefore, secondary mm of tarsus. Vertical incisions are made with fine scis- reconstruction is less difficult, and reversal of the sors, and the shade-like pedicle of tissue is sewn into the procedure only requires transection of the flap upper conjunctiva of the lower lid with 6-0 Vicryl. This where it comes off the upper lid and recession of technique provides support of the lower eyelid and cov- the Müller-conjunctival pedicle to prevent eyelid erage of the cornea. retraction. Patients with extensive second-degree burns (la- sal plate—the thick, fibrous, connective tissue con- gophthalmos and corneal drying not responding to densation at the lid margin—for adequate fixation the use of tears) and third-degree burns of the eye- and (2) that no suture contacts the globe. It is often lids should be stabilized, have their globes pro- difficult to adequately secure the trailing ends of tected, and be evacuated to the continental United the sutures because of periocular burns and the States (CONUS) for definitive care. Patients with application of lubricants to the patient’s skin. these burns usually also have extensive injuries or If necessary before evacuation, non-margin-shar- burns on other body areas, which alone would re- ing temporary tarsorrhaphies may be considered quire evacuation. (Figure 19-13). (Margin-sharing tarsorrhaphies are Burns of the conjunctiva (ocular mucous mem- not commonly used because they distort the lid branes) inevitably lead to scarring and contracture margins, making any subsequent reconstruction and, if not treated early, to symblepharon forma- even more difficult.) Before the technique for non- tion (adhesions between the mucous membranes of margin-sharing tarsorrhaphies is outlined, a cross- the eyelids and the globe). Symblepharon forma- sectional review of the normal lid anatomy is indi- tion is frequently seen with chemical injuries. Ne- cated. The layers of the eyelid going from superficial crotic tissue must be removed and a symblepharon to deep at the level of the tarsal plate are as follows: ring, spacer, or even a large therapeutic contact lens eyelid skin, orbicularis oculi muscle, distal end of should be placed to minimize adhesion formation. the levator aponeurosis, tarsus, and conjunctiva. The eyes should be evaluated at least twice daily, Above the tarsal plate, the layers are as follows: and any early symblepharon should be lysed with eyelid skin, orbicularis oculi muscle, orbital septum, a glass rod or a moistened cotton-tipped applica- preaponeurotic orbital fat, levator aponeurosis, tor. Copious lubricating eye ointment should be Müller’s muscle, and conjunctiva. In the lower eye- used to prevent drying and for patient comfort. lid, the eyelid retractor components are less well Antibiotic ointment should be strongly considered, developed. The equivalent of the levator aponeuro- given the risk of infections in burn wounds. sis is the capsulopalpebral fascia, and the Müller’s muscle equivalent is the inferior tarsal muscle. Oth- Evaluation and Treatment in the Continental erwise, the layers at and below the level of the tar- United States sus in the lower lid are similar to those of the upper eyelid. Evaluation in CONUS of patients with eyelid The non-margin-sharing tarsorrhaphy is created burns should first focus on the status of the eyes. by everting the upper eyelid and incising the con- The following must be ruled out: a ruptured globe;

320 Management of Eyelid Burns intraocular injury; or ocular surface injury due to for mucous membrane grafting and, if tarsal sup- the burn itself, exposure, drying, and corneal in- port is lost, a tarsal substitute such as hard palate fection, which may have occurred during the evacu- mucosal grafts, donor sclera, and other autologous ation process. If any of these injuries is noted, ap- or synthetic materials. In burn patients, the poste- propriate treatment algorithms should be followed rior lamella is involved when injury extends as described above. through the anterior lid structures. Therefore, in Once the eye is determined to be healthy, or when most instances, full-thickness lid loss is present and the ocular injuries are stabilized, evaluation should more-complex procedures combining vascularized focus on the status of the eyelids. Globe protection, pedicle flaps for one lamella and free grafts for the eyelid function, and cosmetic appearance should be other lamella are required. Loss of the middle considered in that order of priority. lamella (septum) usually causes scarring and re- Needed interventions are carried out by the fully stricted lid movement; reconstruction for this prob- trained and experienced military ophthalmologists, lem involves releasing the scar and placing a who will be found at CONUS hospitals. “spacer” to decrease additional scarring. Diminished protraction (lid closure) is caused by Evaluation mechanical restriction, damage to the orbicularis oculi muscle, or injury to the seventh cranial nerve The CONUS evaluation, when completed, should because of adjacent trauma. Inability to close the contain the answers to the following questions: eyelids (lagophthalmos) can be mild to severe and should be treated accordingly as previously dis- • How much and to what degree are the eye- cussed. lids burned? Diminished retraction (lid opening) causes pto- • How much of the eyelids remain and which sis. Mild ptosis may be asymptomatic but more-sig- parts are missing? nificant ptosis can decrease vision if the lid obscures • Is the eyelid ectropic, entropic, or retracted? the pupil and interferes with the visual axis. There- •Is the canalicular system involved or de- fore, persistent ptosis should be repaired for visual stroyed? rehabilitation. • What is the status of the tear film, and Proper closure and anatomical position of the which component has been affected? eyelid are responsible for tear removal. Abnormali- • What is the status of the globe’s protective ties can cause epiphora (tears running out of the mucosal covering? eye onto the cheek). Tests such as the dye disap- • How does the eyelid look relative to a nor- pearance test and the Jones 1 and 2 tests and visual mal eyelid? inspection should be performed to evaluate the status of the tear pump. Extent and Degree of Burns. Reassessment is The dye disappearance test, a diagnostic test of crucial to determine proper short-term and long- tear pumping and drainage, is performed by instill- term treatment and prognosis. Superficial and mild ing fluorescein dye into the eyes and watching for partial-thickness burns can often be conservatively its removal under cobalt-blue lighting. The patient managed. Severe partial- and full-thickness burns is allowed to blink normally but should not wipe require significant immediate attention. Burns pre- the eyes. At 5 minutes, almost all of the dye should viously billed as partial thickness may have probe removed from the eye. If dye is still present, a gressed during transit to full-thickness injuries be- delayed clearance problem exists. Asymmetry of cause of infection, desiccation, or less-than-adequate remaining dye indicates a unilateral (ie, a worse) interim care owing to wartime constraints. problem in the eye with the most dye. Tears run- Status of Remaining Eyelids. The anatomical ning down the cheek may indicate a tear pump status of the eyelids should be evaluated to plan problem. An abnormal dye disappearance test may for reconstruction. A systematic approach should be due to an abnormal tear pump, insufficient tear be used to evaluate the status of the anterior, production to wash out the dye, an obstruction or middle, and posterior lamellae. The eyelids should malposition of the puncta, or a blockage of the be evaluated for their protraction, retraction, tear canalicular–nasolacrimal system. pump function, and cosmetic appearance. Loss of The Jones 1 test, the second diagnostic test of tear anterior lamella requires reconstruction with full- drainage, is performed by instilling fluorescein dye thickness skin grafts or rotational or transposition in the eyes, as was done in the dye disappearance skin and muscle flaps. Posterior lamella loss calls test. In the Jones 1 test, a cotton-tipped applicator

321 Ophthalmic Care of the Combat Casualty is placed under the inferior turbinate to detect dye. Condition of the Canalicular System. Is the If dye is present on the cotton-tipped applicator, canalicular system involved or destroyed? Inspec- tears are cleared normally. If no dye is detected, tion of the canalicular system of the eyelids often however, either the tear pump is malfunctioning or reveals that the punctum is closed or ectropic due the canalicular–nasolacrimal drainage system is to scarring. If ectropic and permanent, surgical cor- blocked. Although the Jones 1 test is a physiologi- rection may be necessary. If the punctum is closed, cal test of tear drainage, no dye may be detected in it can be surgically opened with a punctal dilator about a third to half the patients with normally or sharply cut with a scalpel or Wescott scissors. functioning drainage apparatuses. If the puncta appear normal and if epiphora is The Jones 2 test, the last of the tests of tear drain- present, the cause should be determined using the age, is performed after an abnormal (no dye de- dye disappearance test and Jones 1 and 2 tests (detected) Jones 1 test. After the Jones 1 test, residual scribed above). Additionally, the canaliculi should dye is irrigated from the conjunctival cul-de-sac. be irrigated with physiological saline solution in a Then clear saline is irrigated through the canaliculi 3-mL syringe and a blunt 23-gauge cannula. If fluid while an attempt is made to detect dye beneath the reaches the nose, then the lacrimal drainage system inferior turbinate. If no fluid is recovered from the is open. If fluid does not reach the nose but instead nose after irrigation, then a blocked drainage sys- drains out the opposite punctum (ie, out the upper tem is present. If clear fluid is detected, then the when the lower punctum is irrigated), then a naso- tear pump is malfunctioning and is unable to pump lacrimal duct obstruction is probably present. How- dye into the lacrimal sac; because fluid is recovered, ever, if fluid does not reach the nose but drains out however, the drainage system is anatomically the same punctum that is being irrigated, then the patent. On the other hand, if dye enters the nose canaliculus being irrigated is obstructed. Note that with irrigation, then the tear pump functions to this is similar to the Jones 2 test discussed previ- push dye into the tear sac, although the drainage ously. system might be functionally or partially blocked. Nasolacrimal duct obstruction is uncommon in Finally, if the lower eyelid seems lax or there is burn patients unless severe facial burns around the punctal ectropion, the tear pump may not be func- nose involving the bone are present, or if the pa- tioning well. tient has a midfacial injury from a blast. If a naso- Position of the Eyelids at Rest. Is the eyelid lacrimal duct is obstructed, the patient may need a ectropic, entropic, or retracted? In addition to the dacryocystorhinostomy (DCR). In this procedure, dynamic lid position and function discussed above, an osteotomy is created in the lacrimal sac fossa and the static position of the eyelids at rest should be a direct connection is made between the lacrimal determined. sac and the nasal cavity. A DCR can be performed An ectropic lid may cause exposure keratitis, epi- endoscopically through the nose or externally phora, FB sensation, and blurry vision. Ectropion in through a Lynch skin incision in the medial canthal burn patients is usually cicatricial, either from direct area. To promote mucosal epithelialization of the lid involvement or transferal of traction from adja- bypass tract, anterior and posterior mucosal flaps cent tissue such as a cheek burn. Treatment is aimed can be created from the lacrimal sac and nasal mu- at releasing the traction and replacing the lost tissue. cosa, which are sutured together. Additionally, a On the other hand, an entropic lid is generally silicone stent is usually placed through the canali- more worrisome than an ectropic one because the culi and through the osteotomy and into the nose sequelae occur more rapidly. An entropic lid can to reduce cicatricial closure of the mucosal bypass cause a mechanical keratitis from lashes or kerati- tract. The stents are removed once healing is rela- nized lid skin rubbing against the cornea, which can tively complete, usually at about 3 months postop- cause significant corneal injury if not immediately eratively. addressed. Entropion in burn patients may be due Canalicular obstruction or destruction is more to conjunctival scarring, although this is less com- common with eyelid burns. If the burn injury is mild mon in thermal than in chemical burns. A patient (superficial), simple canalicular intubation as pre- with preexisting lid laxity may have spastic entro- viously discussed may be adequate. If severe (par- pion due to ocular irritation after a burn injury. tial- or full-thickness), however, canalicular re- Treatment is aimed at relieving the irritation and construction is very difficult, owing to scar formation, breaking the cycle of spasm. and the patient may eventually require a conjunctivo- Eyelid retraction in burn patients is usually due dacryocystorhinostomy (C-DCR) with a Jones tube. to scarring and is treated much like an ectropion. In this procedure, an external Lynch incision is

322 Management of Eyelid Burns made, much like that in a DCR. An osteotomy at The Schirmer tests and the basal tear secretion the lacrimal sac fossa is created with rongeur for- test measure the aqueous component of the tear ceps. A no. 69 Beaver blade is passed through the film. Tear break-up time, on the other hand, mea- conjunctiva just lateral to the caruncle and into the sures the stability of the tear film on the surface of lid through the osteotomy and into the nasal cav- the eye. Nonanesthetic fluorescein dye (usually ity. A Pyrex Jones tube is then passed through this from moistened fluorescein strips) is placed onto tract into the nose and secured into place with a the ocular surface. While at the slitlamp and under suture at the lid margin. The Lynch incision is closed cobalt-blue light, the patient is first asked to close in two layers, and the Jones tube fixation suture is his or her eyes, then to open them and resist blink- removed in 7 to 10 days. The Jones tube bypasses ing. The observer then counts the number of sec- the entire blocked canalicular system and allows the onds before the tear film breaks up on the ocular tear lake to drain directly into the nose by means of surface, which, under the blue light, is seen as a dark gravity and capillary action. spot appearing in the uniform green fluid layer on Status of the Tear Film. Which components have the cornea. The tear film should normally be stable been affected? The tear film should be evaluated for 15 seconds. Early break-up implies either insta- for its quantity and quality because eyelid burns bility of the tear film because of an insufficient se- can alter all components. The meibomian glands at baceous layer, allowing early evaporation, or poor the lid margin can be damaged, reducing the seba- wetting because of an insufficient mucous layer on ceous (lipid) layer of the tear film; this causes de- the cornea. Topical anesthetics should not be used creased lid lubrication and increased tear evapora- in this test, as they alter the test results. tion. If the conjunctiva is significantly involved, Tear composition analysis and impression cytol- then the accessory glands of Krause and Wolfring ogy are advanced techniques that will not be dis- or even the main lacrimal gland could be injured. cussed here. Nevertheless, ophthalmologists can If this is the case, the aqueous component of the appreciate that a significant alteration in any of the tear film would be diminished, resulting in signifi- tear components could cause ocular surface disease, cant keratitis sicca (see Figure 19-6). Likewise, be- patient discomfort, and visual degradation. cause the mucous layer of the tear film is made by Status of the Mucosal Covering. What is the sta- conjunctival goblet cells, conjunctival injury can tus of the globe’s protective covering? As stated cause poor corneal wetting if the inner mucous tear earlier, burn injury involving the conjunctiva may film layer is compromised or missing. result in symblepharon and the globe’s being fixed Assessment of the tear film is done mainly with to the eyelids. Careful examination is required to Schirmer’s tests, tear break-up time, direct visual- reduce the amount of symblepharon formation and ization, and, in some medical centers, chemical to plan for replacing a mucous membrane layer on analysis and impression cytology. Schirmer strips— the globe and eyelids. standardized strips of filter paper—are placed in Comparison With a Normal Lid. How does the the inferior conjunctival cul-de-sac and draped over eyelid look relative to a normal eyelid? Once the the lower eyelid. The Schirmer 1 test measures basal functional and ocular protective status of the lids and reflex tear production. It involves putting the has been evaluated and addressed, then attention strips onto an unanesthetized eye. The amount of can be directed to eyelid aesthetics. Common con- strip wetting is measured in millimeters after 5 min- cerns include skin texture, lash loss, hypertrophic utes (normal = ≥ 15 mm). The Schirmer 2 test mea- scars, lid and canthal angle positions, medial can- sures reflex tear production. It involves placing the thal webbing, and eyebrow hair loss. strips onto the eye after topical anesthetic is applied. The inferior turbinate is then irritated with a cot- Treatment ton-tipped applicator, and the amount of wetting is measured (normal = > 10 mm). The basal tear Treatment in CONUS includes all the lower-ech- secretion test is a variant of the Schirmer tests, in elon treatments described. These procedures are which the strips of filter paper are placed into the often repeated once the patient has arrived in a anesthetized eye after excess tears have gently been CONUS hospital because of persistence of the signs removed with a cotton-tipped applicator. The or worsening of the condition. An oculoplastic sur- amount of wetting is measured after 5 minutes (nor- geon should be consulted to perform definitive mal = ≥ 10 mm). Care must be taken when drying reconstruction or emergent reconstruction of a se- the surface of residual tears, as excess vigor may verely burned eyelid. Definitive delayed reconstruc- stimulate reflex tearing. tive surgery should occur no earlier than 3 months

323 Ophthalmic Care of the Combat Casualty after the initial injury. If surgery can be delayed surgery. Scar relaxation may be expedited by longer (up to 1 year), the outcome of reconstruc- manual massage, use of topical vitamin E or cocoa tion may be improved, as postoperative cicatricial butter, and constant, long-term pressure to the changes are reduced by then and better revascu- wound area using custom-fitted masks made of sili- larization of the injured tissue will have occurred. cone, Flexan, or plastic, all of which can be manu- However, visual rehabilitation often necessitates factured by Uvex or Jobst.13 Pressure splints placed earlier repair. directly on the eyelids are impractical because they Reconstruction of the burned eyelids should fo- interfere with vision and put pressure on the eye. cus first on protecting the eye (protraction), then However, lid malpositions due to adjacent tissue on visual function (retraction to clear the visual scarring (eg, on the cheek) respond very well to axis), and finally, for the patient’s psychological custom-fitted pressure splints. Given the slow pro- well-being, on cosmetic appearance. Multiple process of rehabilitation to give the patient a sense of cedures are available to deal with the complex na- progress toward recuperation, it is often helpful to ture of the cicatrized eyelid and are beyond the engage him or her as much as possible in massage scope of this book. However, for a basic understand- and stretching regimens. ing of what procedures are available, a brief descrip- Once the cicatrix has maximally relaxed, or if tion of selected procedures is provided. more-immediate intervention is required to protect Treatment modalities in CONUS hospitals in- the eyes or allow the patient to see, surgical reha- clude conservative treatment to allow scar relaxation bilitation should proceed in an organized, stepwise and maturation; restoration of lost eyelid tissue; and fashion. The patient should be well-informed about correction of eyelid and canthal malpositions, disor- the long road to recovery and the need for multiple ders of eyelid retraction and protraction, trichiasis, operations and revisions. disorders of the mucosal lining of the eyelid, and ab- Restoration of Eyelid Skin. Loss of eyelid skin normalities of the tear drainage system. is treated with skin grafts or, if undamaged eyelid Conservative Treatment. In eyelid burn patients, tissue is available, transposition flaps. Cultured if the eyes are well-protected and visual function is autogenous skin21 and alloplastic material are avail- adequate, then definitive repair should be delayed able for use22 in patients without an adequate skin up to 1 year, if possible. Cutaneous and subcutane- source (Exhibit 19-1). The most commonly used ous burn scars are slow to mature, and maximum free-graft sources for the eyelids include the upper natural relaxation of scar tissue is desired prior to eyelid skin from the normal contralateral lid (if

EXHIBIT 19-1 SKIN GRAFTS FOR RESTORATION OF LOST EYELID TISSUE

Autologous grafts: In the absence of an adequate skin source, a few of the patient’s own skin cells may be sent for culture. Unfortunately, the process of growing human skin is time-consuming and expensive, and even in light of the screening and processing methods used, a concern regarding disease transmission accompanies all grafts—even when the donor and the recipient are the same person.

Alloplastic grafts: Alloderm (LifeCell Corp, The Woodlands, Tex) is an acellular, nonimmunogenic dermal grafting material that can be used in place of skin. Because it is made from an inert substance, the graft lacks epidermal cells, and the graft recipient’s skin cells must migrate onto the biological bed for resurfacing. The process may be even slower if the adjacent tissue also suffered thermal damage.

Allografts: As an alternative, nonimmunogenic allografts can be used. Apligraf (Novartis Pharmaceuticals Corpora- tion, East Hanover, NJ) is harvested from neonatal foreskin, which is then processed to make it nonimmunogenic. This material, being human in origin, has intact epithelium; therefore, the graft may heal faster.

324 Management of Eyelid Burns

cheek, if possible) to keep the graft on stretch and decrease contraction. Antibiotic ointment, a nonad- hesive dressing, and a pressure patch or bolster splint are placed on the graft and secured with tape to prevent hematoma under the graft, which might increase the likelihood of graft failure. The patch and the traction suture are removed in approximately 5 days. In defects that are smaller or that require a vascularized skin source, transposition flaps (eg, from the upper to the lower eyelid with the pedicle based laterally) may be useful. However, the skin adjacent to the burn wound is often damaged as well, and so these transposition skin flaps are not used often. In the medial canthal area, a midline glabellar or median forehead flap may be used for recon- Fig. 19-14. This photograph depicts a full-thickness skin struction. graft to an eyelid defect to correct cicatricial ectropion. When there is full-thickness loss of eyelid tissue, The skin graft may be taken from the upper eyelid, the both posterior and anterior lamellae require recon- retroauricular or periclavicular areas, or the inner arm or struction. Surgical repair necessitates having at least inner thigh. Thin, pliable, hairless skin is preferred. The one vascularized lamella. In burns severe enough skin-grafted lid is then put on traction with a Frost suture, to destroy the entire eyelid, it is unlikely that there and a pressure dressing is placed over the graft for 1 week to prevent hematoma formation below the graft. is adequate adjacent well-vascularized skin, especially for the upper eyelid. Therefore, most reconstruction of the upper eyelid utilizes posterior lamella pedicle flaps with anterior lamella free present), retroauricular skin, supraclavicular and grafts (described above). If the cheek and face skin infraclavicular skin, upper inner arm (volar surface) are not compromised, a Mustarde flap with a mu- skin, and inner thigh skin20,23 (Figure 19-14). cosal membrane graft (eg, from the hard palate) can Grabosch and colleagues22 reported successful use be used to reconstruct the lower eyelid. Otherwise, of prepuce skin for the eyelid in severely burned a posterior pedicle flap must be used as well. patients. The most common techniques for large, full- Successful skin graft healing requires a relatively thickness reconstruction of the lower eyelid include healthy vascular bed. In patients with partial-thick- the modified Hughes tarsoconjunctival flap, the ness or localized full-thickness burns, the posterior Hewes laterally based tarsoconjunctival flap, and lamella of the eyelid may be intact, with blood sup- the Mustarde flap. In the modified Hughes proce- plied by the palpebral conjunctiva and Müller’s dure (Figure 19-15), the upper eyelid is everted over muscle. In such cases, the eyelid scar is incised, or a Desmarres retractor, and a Beaver blade is used a lid crease incision can be performed and the to incise the conjunctiva and tarsus approximately deeper cicatrix released, until the eyelid is mobile 5 mm above the lid margin for the length of the and has full excursion. The lid is then put on trac- lower-lid defect to be filled. The dissection is car- tion with a double-armed 4-0 suture through the ried out superiorly in a plane between Müller’s lid margin. The defect is measured, and an over- muscle and the levator aponeurosis. The conjunc- sized graft (usually one-and-a-half to two times the tiva is incised vertically in a superior direction. The size of the defect) is also measured and then har- flap is then brought down into the lower eyelid vested from an appropriate donor site. Care should defect and sewn into place with 6-0 Vicryl sutures. be taken to keep the graft as thin as possible for A full-thickness skin graft or comparable material optimal function and cosmesis. In some instances, is harvested, placed on the pedicle flap, and sewn a thick, partial-thickness skin graft (0.4 to 0.5 mm into place with 6-0 fast-absorbing gut suture. in depth) harvested with a dermatome may give good The wound is dressed in much the same way as a results with comparatively little contracture.22–24 skin graft. The reconstruction is allowed to heal for The graft is then sewn into place with 6-0 fast-ab- approximately 6 to 8 weeks, sometimes longer, de- sorbing gut sutures. The traction suture is put on pending on the vascular status of the burned area. traction and taped into place (on the forehead or Once healed, the pedicle is transected where it joins

325 Ophthalmic Care of the Combat Casualty

a b

c d

Fig. 19-15. The Hughes tarsoconjunctival advancement flap for the reconstruction of the lower eyelid is a staged procedure, requiring the globe to be covered for 6 weeks. The pedicle is then transected and the lid margin is reconstructed. (a) The lower eyelid defect is shown. The tarsoconjunctival flap is being developed. (b) The tarsoconjunctival flap is brought down into the lower lid defect. (c) Redundant lower eyelid skin is brought over the tarsoconjunctival flap, as in this case, or a full-thickness skin graft can be placed over the mucosal flap. (d) The well-healed pedicle can be transected. The lower lid margin can then be reformed. the upper eyelid and separated into anterior and pos- nylon sutures. The posterior lamella is recreated terior lamellae. Excess skin is excised, and the mu- with mucous membrane and often a rigid material cosa is draped over the lid edge, extending over the to act as a tarsal substitute (eg, banked sclera, high- lid margin. It is then sewn in place with 6-0 fast-ab- density porous polyethylene [Medpor, mfg by Porex sorbing gut. The mucosa exposed to the environment Surgical Inc, College Park, Ga], nasal septal carti- eventually becomes keratinized. The conjunctiva and lage, and auricular cartilage). These materials usu- Müller’s muscle may need recession if the upper lid ally require a mucous membrane covering, such as is retracted after transection of the pedicle flap. buccal mucosa. Alternatively, hard palate grafts or The Hewes flap is similar to the modified Hughes Alloderm (mentioned above) may be used for the except that it is a laterally based tarsal conjunctival posterior lamella without requiring mucous mem- flap with a free skin graft. Because the flap is based brane grafting. at the lateral canthus, the flap does not obstruct the The most common techniques used for large, full- palpebral fissure. Therefore, it is a single-stage pro- thickness upper eyelid reconstruction include the cedure. Cutler-Beard procedure, the glabellar flap, and the The Mustarde flap requires an extensive under- laterally based transposition flap from the suprabrow mining of skin from the lateral lower lid extending area. The Cutler-Beard procedure (Figure 19-16) in- to the preauricular area and inferiorly toward the volves incising the lower eyelid full thickness be- angle of the jaw. The skin flap is then rotated low the tarsus (approximately 6 mm) and extend- superomedially and sewn into place with deep 5-0 ing the width of the upper-lid defect. The incision or 4-0 Vicryl sutures and 6-0 fast-absorbing gut or is extended directly inferiorly at each end of the

326 Management of Eyelid Burns

a b

c d

Fig. 19-16. The Cutler-Beard advancement flap for the reconstruction of the upper eyelid is also a staged procedure. (a) In this photograph, the upper-lid defect is partially covered by the lid plate. A full-thickness incision is made across the lower eyelid, as shown. (b) The conjunctival flap is advanced superiorly. (c) The conjunctival flap is sewn into the upper-lid defect, and the skin flap is similarly brought underneath the lower-lid margin bridge and into the upper-lid defect. A tarsal substitute, such as sclera, may be placed between the two lamellae. (d) The defect is repaired. The pedicle is transected after 6 weeks, and the upper-lid margin is reconstructed.

horizontal incision so that the full-thickness pedicle graft of hard palate tissue does not work well in can be brought behind the bridging lid margin of the upper lid because the graft tends to irritate the the lower lid and into the upper eyelid defect. The corneal surface with lid excursions. The temporally lamellae of the pedicle are separated and a tarsal based transposition flap has a less well-defined substitute (such as those for the Mustarde flap, blood supply and, therefore, may not be as useful above) is sewn between the two lamellae at the level in cases of complete loss of the upper eyelid. of the superior tarsus. The pedicle is then sewn into In cases of full-thickness loss of both upper and the defect in multiple layers with 6-0 Vicryl sutures. lower eyelids on the same side, reconstruction is The tarsal substitute is sewn edge to edge with any extremely difficult. The main goal, however, is to remaining upper-lid tarsus. The skin is closed in the protect the globe. In these (albeit rare) cases, we usual fashion. have mobilized forniceal and bulbar conjunctiva The glabellar flap is essentially a medially based from the upper and lower fornices and sewn them transposition flap that is brought down from the together. This provides a mucosal covering for the midline of the forehead and across the upper lid to cornea. The exposed, nonepithelialized surface of fill in the defect. The blood supply is based off the the mobilized conjunctiva is covered with skin supratrochlear vessels. This flap mainly supplies grafts. A small opening in the conjunctiva may be anterior lamella and, if used for full-thickness de- left centrally and the edge of the mucosa sewn to a fects, a mucous membrane graft must be used to corresponding opening in the skin graft. The open- line the defect, and a tarsal substitute is required to ing provides a small aperture for vision and for give the lid rigidity. Unlike in the lower eyelid, a monitoring of the corneal status.

327 Ophthalmic Care of the Combat Casualty

Eyelid Malpositions. Cicatricial ectropion is the most common eyelid malposition caused by eyelid burns. The ectropion may stem from direct eyelid tissue scarring or from transmission of contracture from adjacent tissue (eg, cheek or forehead). Treat- ment is aimed at releasing the tension on the eyelid, preferably at the site of scarring. Eyelid cicatricial ectropion is caused by shorten- ing or scarring of the anterior lamella. The main treatment is relaxation of the scar tissue. If the scar is small and damage to surrounding tissue is minimal, the scar can be incised with Z-plasties to reduce the tension on the lid by changing the vector of pull. Unfortunately, in burn patients, the surrounding tissue is often injured, and simple Z- Fig. 19-17. Midface lifting procedure used to release and plasty scar relaxation is not adequate to correct the recess the midface soft tissue. A subperiosteal plane is ectropion. dissected along the anterior surface of the maxilla. Care Similarly, advancement or rotational skin–muscle is taken to avoid injuring the infraorbital neurovascular flaps from adjacent sites may be used to fill in the bundle, as shown in the photo to the left of the retractor. This procedure facilitates lid elevation and ocular cov- tissue shortage after the scar is released. In cases of erage using available skin and soft tissue, possibly cir- significant adjacent tissue loss or burn injury, free cumventing the need for a skin graft. grafting is often needed.25 The free graft of choice is full-thickness skin graft from the upper lid, retroauricular area, periclavicular area, inner arm, position in anticipation of future contraction. If an or inner thigh where the skin is thin and hairless. If infraciliary incision is used, the anterior lamella these areas are not available, thick split-thickness may be augmented with a skin graft as well. skin grafts from hairless areas may be harvested If additional coverage of the medial globe is re- with a dermatome set between 0.4 and 0.5 mm thick- quired because of medial lid retraction, a medial ness. Alternatively, Alloderm or Apligraf (see lid margin adhesion procedure may be performed above) may be used. After grafting, the lid should by deepithelializing the canalicular portion of the be placed on stretch and a pressure patch placed as eyelid margin and suturing it together using 6-0 described above. Vicryl sutures (Figure 19-18). Care must be used to In less severe cases of contracture or in cases with avoid damaging the canalicular system. Bowman deeper scarring, a subperiosteal midface elevation lacrimal probes may be passed into the canaliculi or suborbicularis oculi fat elevation (the SOOF lift) during the procedure as a guide to avoid damag- may relieve enough vertically oriented tension from ing the canaliculi. the lower face to correct the eyelid ectropion (Fig- Entropion is less commonly found in burn pa- ure 19-17). The SOOF lift is accomplished through tients unless there has been a chemical burn to the either a lower-lid infraciliary or transconjunctival conjunctival surface. Otherwise, entropion occurs approach to the inferior orbital rim. Once the rim is in burn patients only if mild senile entropion is al- reached, the periosteum is incised just inferior to ready present. If underlying lower-lid laxity, over- the orbital rim, and a subperiosteal dissection is riding orbicularis, or retractor dehiscence are carried out toward the gingival sulcus. The infraor- present, then irritation from a burn injury or lash bital neurovascular bundle is left intact. The lower- debris may cause a spastic entropion. Spastic en- face periosteum may be released to give further el- tropion can be treated by removing the offending evation. The deeper facial tissue is suspended with cause (eg, an FB) and providing copious lubrica- 4-0 nylon sutures to the periosteum at the inferior tion to break the spastic lid closure cycle. Quickert– orbital rim and the lower lateral rim. Alternatively, Rathburn sutures may be helpful to overcome this small suture fixation holes may be drilled at the problem. They are performed by passing double- orbital rim for attachment. The transconjunctival armed sutures (eg, 4-0 chromic) through the infe- incision may be closed with 6-0 fast-absorbing gut rior conjunctival fornix, full-thickness through the suture, and the lateral canthal tendon is resus- lid, and exiting just under the lashes. Several such pended to the lateral orbital rim at a more elevated sutures may be used across the eyelid to evert it.

328 Management of Eyelid Burns

Fig. 19-18. A medial canthal lid margin adhesion procedure performed to maximize globe protection. Care is taken to avoid injury to the canalicular system. Drawing: Courtesy of Department of Medical Illustrations, Brooke Army Medi- cal Center, Fort Sam Houston, Tex.

More severe cases of senile entropion require lower- lid tissue is in very short supply, glabellar flaps or lid tightening (Figure 19-19), reattachment of the skin grafts may be used to augment the medial can- lower-lid retractor to the inferior tarsal border, and thus, and laterally based flaps and skin grafts may occasional debulking of the overriding preseptal be used for the lateral canthus. If the medial can- orbicularis muscle. thal tendon is displaced, it must be resuspended to In case of cicatricial entropion, the posterior the posterior lacrimal crest so the lid is apposed to lamella needs lengthening with mucous membrane the globe. Similarly, the lateral canthus must be grafts, tarsal substitutes, or both, as described suspended to approximate the lateral lid to the above. It is important to repair entropion, because globe (see Figure 19-19). the in-turned lashes can irritate and damage the The medial canthal tendon can be isolated corneal surface. through a skin incision along a medial canthal lid Canthal Malpositions. Burn scars may cause dis- fold or incised scar. The tendon is resuspended to placement of the medial and lateral canthal tendons the periosteum with a permanent suture. If this is from their normal positions. They may be dragged not secure, a suture hole may be drilled into the lac- in any direction and usually are displaced away rimal crest from which to suspend the tendon. from the globe, interfering with proper globe ap- Screws, plates, and anchors are available for sus- position and tear pump function. Repair of canthal pension; however, the bone in the medial canthal malposition is similar to repair of eyelid malposi- area is often thin and cannot support this hardware. tion. Scar relaxation is required and tissue augmen- In severe cases, transnasal wiring may be required tation may be accomplished with transposition or for telecanthus repair. free grafts. Additionally, the medial canthus is of- The lateral canthal tendon can be resuspended ten subject to webbing, and the canthal tendons of- with a lateral tarsal strip procedure to the perios- ten need resuspension to their proper anatomical teum at the lateral orbital tubercle. If the tendon is positions. damaged, a lateral rim periosteal flap can be mobi- Canthal webbing is usually addressed by incis- lized for lateral lid attachment. Also, the tendon ing and relaxing the scarred tissue. Combinations may be directly secured to the lateral rim with a of Z, Y-V and W-plasties are often required. If eye- drill hole for the permanent suture.

Fig. 19-19. A horizontal lid-tightening procedure similar to a lateral tarsal strip is performed to prevent eyelid laxity and maximize globe protection. Drawing: Courtesy of Department of Medical Illus- trations, Brooke Army Medical Center, Fort Sam Houston, Tex.

329 Ophthalmic Care of the Combat Casualty

Disorders of Eyelid Retraction. For the upper is more prone to dry eye problems, and a conserva- eyelid, the eyelid retractors consist of the levator tive approach to ptosis repair is warranted—espe- palpebrae and its aponeurosis and Müller’s muscle; cially when function is moderate to poor—because for the lower eyelid, the retractors are the capsulo- the indicated procedures usually cause some degree palpebral fascia and the inferior tarsal muscle. of lagophthalmos. Proper retractor function, especially of the upper Disorders of Eyelid Protraction. The orbicularis lid, is required for good visual function. Upper re- oculi muscle forms part of the anterior lamella of tractor dysfunction results in ptosis or a droopy lid, the eyelids and is, therefore, commonly injured in which may block the visual axis. Lower retractor dys- eyelid burns. The orbicularis oculi muscle forms the function may result in a higher-than-normal lid posi- main protractor muscle. As stated earlier, proper tion, or reverse ptosis; however, this does not usually eyelid closure is needed for eye protection, distri- interfere with the visual axis and is less of a con- bution of the tear film, and tear pumping. In most cern. Indeed, in a burn patient, a slightly elevated eyelid burns, inability to close the eyes is due to lower lid may help protect the eye from exposure. (1) cicatricial eyelid retraction or (2) ectropion due Upper-lid ptosis is not very common in burn to anterior, posterior, or middle lamella scarring. patients unless the levator aponeurosis has been When the scar is released, the lids often are able to damaged or the tissue was injured from a blast. In close normally. early stages of burn injury, ptosis may be mechani- In more-severe burns with damage to the orbicu- cal from swelling. In the chronic stages, however, laris muscle, eyelid protraction may still be ham- persistent ptosis is more likely due to middle pered despite release of all cicatricial processes. In lamella scarring or retractor damage. The amount such instances, the weak or absent orbicularis of the defect (in this case, ptosis and levator func- muscle requires adjunctive support. Surgical pro- tion) will guide intervention. Additionally, forced cedures can be aimed at static or dynamic eyelid generations of eyelid closures (isometric contrac- closure. tions of the lids) should be performed if cicatricial Static eyelid closure procedures decrease the restriction of lid excursion is suspected. palpebral fissure, giving greater protection to the If the ptosis is primarily due to scarring, then eye and decreasing the distance that a weakened surgical release of the scar may be required. Intra- orbicularis muscle would have to move the lid for operative assessment for multiple causes is usually full closure. These procedures include those de- required; any new findings should be addressed at scribed for correcting cicatricial ectropion/retrac- the time. Once the scar is released, ptosis may still tion (eg, skin grafting, SOOF lift) (see Figures 19-14 be present because of dehiscence of the levator apo- and 19-17). The lateral canthal tendon may also be neurosis, which requires repair. In general, ptotic supraplaced, and the lower lid can be supported lids with good levator function respond well to with semirigid spacers such as hard palate mucosa aponeurotic surgery, those with moderate excursion (Figure 19-20), sclera, ear or septal cartilage, may do well with levator muscle surgery, and those Alloderm, or Medpor. Additionally, tarsorrhaphies with poor function require frontalis slings. Detailed may be done both laterally and medially (avoiding description of ptosis surgery is available in any the canalicular system) to add further support and oculoplastic textbook. Furthermore, a burn patient lid closure (see Figure 19-18).

b a

Fig. 19-20. (a) Mucosa from the patient’s hard palate has been harvested with a radiofrequency mucotome unit for mucosal lengthening of the eyelid. (b) Sche- matic diagram of the hard palate mucosa donor site. Drawing: Courtesy of Depart- ment of Medical Illustrations, Brooke Army Medical Center, Fort Sam Houston, Tex.

330 Management of Eyelid Burns

Dynamic eyelid closure is achieved with place- needed, to protect the eye from irritation (Figure ment of either upper-lid gold weights or palpebral 19-21). However, this may not be the best option in springs. The upper-lid gold weight allows gravity thermally damaged eyelids with tissue loss. Cryo- to pull the eyelid down when the levator palpebrae therapy is also useful in eliminating lash bulbs. Less is relaxed. The gold weight is placed in a supratarsal damage to adjacent tissue occurs when the lid is position and fixed with permanent sutures. The lo- split into anterior and posterior lamellae at the gray cation is accessed through a standard blepharo- line and the lash follicles are selectively frozen. In plasty incision with dissection carried down to the severe burns, the anterior lamella can be recessed anterior surface of the tarsal plate. Palpebral springs away from the lid margin and an intervening buc- are similarly placed. They fit into the upper and cal mucosal membrane graft can be placed with or lower eyelids and close spontaneously when the without meticulous extirpation or excision of all the levator is relaxed. With prolonged use, ptosis from offending lashes. dehiscence of the levator aponeurosis may occur. Disorders of the Mucosal Lining. In burn pa- More-advanced techniques have been tried in patients, abnormalities of the mucosal lining include tients with facial nerve palsy using temporalis symblepharon, eyelid posterior lamella cicatrization muscle transfers and exogenous nerve stimulation; or tissue loss, and bulbar (eyeball) conjunctiva loss. this information is available in textbooks on facial Definitive repair of symblepharon varies according plastic and head and neck reconstruction and there- to severity. Mild symblepharon may simply be sur- fore will not be further discussed here. gically lysed. Moderate symblepharon may require Trichiasis. Eventually, trichiasis (inwardly di- mucosal rearrangement after lysing. Rearrangement rected lashes) causes significant damage to the cor- can be accomplished with multiple Z-plasties and nea and to visual function. In the early stages, until rotational or transposition conjunctival flaps to re- the burn injury matures, copious lubrication and duce tension between the bulbar and the palpebral selective forceps epilation are adequate. In the conjunctivae. chronic stage, however, definitive treatment is in- More-severe cases have insufficient conjunctival dicated. If there are only a few offending lashes, tissue, and mucosal membrane grafting is required. they may be permanently destroyed using electroly- Autogenous mucosal membrane sources (discussed sis units or a monopolar cautery with a fine needle above) include buccal or lip mucosa and hard pal- tip directed at the lash bulbs. Argon laser at a ate mucosa (which is usually reserved for the lower slitlamp can be used to ablate the lash bulbs in an eyelid to give it vertical support). Once the symble- anesthetized lid. pharon is lysed, the defect is filled with mucous If a group of lashes are localized in one area, then membrane graft tissue. The buccal mucosal graft a full-thickness wedge resection can be used to re- can be harvested freehand with a scalpel and move them. The wedge resection can also be used Wescott scissors, and then cauterized for hemosta- to remove a section of distorted lid margin, if sis. The graft is sewn into place with 7-0 Vicryl or

a b

Fig. 19-21. (a) A pentagonal wedge resection permits (b) reformation of a smooth eyelid contour and removal of trichiatic lashes to restore normal tear pump mechanisms and to avoid ocular irritation.

331 Ophthalmic Care of the Combat Casualty

6-0 fast-absorbing gut sutures. Occasionally, a To prevent reocclusion, a stent may be placed or a symblepharon ring (ie, a plastic or silicone con- two-snip procedure performed. The two-snip proce- former ring to prevent conjunctival fornix contrac- dure is performed by placing one blade of a sharp tion) must be placed until the mucosa heals in place. Wescott scissors into the punctum and the other onto Alternatively, double-armed fornix reconstructive the mucosal surface of the lid. The punctal orifice is sutures placed full thickness through the fornix and then cut on the mucosal side of the lid. This process is out through the eyelid skin may be used to hold repeated just medial or lateral to the initial incision the mucosal grafts in place. Full-thickness buccal so that a V-shaped wedge of the vertical canalicular mucosal grafts work well on the eyelid but are too wall on the mucosal side of the lid is excised, creat- thick for the ocular surface. A mucotome, used to ing a large, posteriorly placed punctum. harvest ultrathin mucosal membrane, may be also Canalicular stenosis can be addressed with se- be used for bulbar conjunctival replacement. An quential dilation by passing Bowman lacrimal ultrathin graft avoids the erythematous appearance probes of increasing size. Once adequate dilation of full-thickness mucosa on the globe. is achieved, the drainage system must be intubated Repair of eyelid posterior lamella loss was dis- with Crawford tubes or similar stents to prevent cussed above. Repairing posterior lamellae ad- restenosis. Additionally, the canaliculi may be di- dressed release of the scar, replacement of mucosal lated with a balloon catheter such as the LacriCATH surfaces, and use of tarsal plate substitutes (see Fig- (mfg by Atrion Medical, Birmingham, Ala). Once ure 19-20). Bulbar conjunctival loss may occasion- dilated, intubation is still required and should be ally heal spontaneously, provided there is no palpe- left in place for 6 to 12 months. If a canaliculus is bral mucosa loss that would cause adhesions and obstructed and the obstruction is focal and distal symblepharon. In most cases, grafting is required. to the medial canthus, then the obstructed section Bulbar mucosa can be replaced with autogenous can be excised and the canalicular portion of the lid bulbar conjunctiva from an uninjured site or oppo- margin primarily repaired over an intubated canali- site eye. If unavailable, ultrathin buccal mucosal cular system. If the obstruction is focal but close to membrane is a good alternative. Shimazaki and the medial canthus, then a Bowman probe can be colleagues26 reported the use of amniotic membrane forced through the obstruction and into the sac. transplantation for ocular surface reconstruction in Alternatively, a holmium (Ho) laser with an patients with chemical and thermal burns. intracanalicular probe can be used to ablate the Tear Drainage System Abnormalities. In burn obstruction. The canalicular system is then intu- patients, the most common abnormalities of the tear bated with the hope that mucosal epithelium will drainage system involve the puncta, canaliculi, migrate toward the center—from normal canalicu- and tear sac, owing to the burn injury itself and lar mucosa along the stent toward the lacrimal sac scar formation involving the eyelids. It is very un- and vice versa. Ophthalmologists should note that common for the nasolacrimal duct to be involved the success of procedures decreases whenever sur- because it is protected by the bony nasolacrimal gical insult occurs adjacent to tissue damage. If canal. In cases of blast injury or severe burns to the canalicular obstruction persists or is more-severe, midface involving the facial bones, an injury to then the entire canalicular system must be bypassed the nasolacrimal duct may occur. Malpositions of via a C-DCR (described above). the eyelid (see earlier discussion) can affect the tear If scarring or strictures are mild, then injured lac- pumping mechanism even though normal rimal sacs may be amenable to simple intubation tear drainage system components are present. Prob- of the lacrimal drainage system with or without lems directly involving the puncta, canaliculi, balloon dilation. If more-severe, the sac must be lacrimal sac, and nasolacrimal duct are addressed surgically explored with an external skin approach here. and a DCR or C-DCR may be required to restore Punctal stenosis or occlusion from scarring is tear drainage. common in eyelid burns. Mild stenosis can be ad- Finally, obstruction of the nasolacrimal duct may dressed with sequential punctal dilation with or be partial or complete. Partial obstruction may re- without placement of a punctal stent. If the stric- spond to balloon catheter dilation and intubation ture is localized to the punctum, a punctal plug may along with an antibiotic and steroid regimen to re- suffice as a stent. If the punctum is occluded or if duce postoperative scarring from inflammation and the stenosis is refractory to dilation, then the punc- bacterial colonization. For complete or refractory tum may be surgically opened with a supersharp partial obstructions, a DCR with intubation should blade, sickle knife, or sharp-tipped Wescott scissors. be performed.

332 Management of Eyelid Burns

SUMMARY

Management of eyelid burns—first-degree, or Acute and subacute management focuses on pro- superficial; second-degree, or partial-thickness; and tecting the eye and its visual potential and on lim- third-degree, or full-thickness—occurs at all iting the extent of the damage that has occurred to echelons of care, from battalion aid stations at the the eyelids and surrounding tissue. Long-term man- 1st echelon to medical centers in CONUS. At each agement involves critical evaluation of the injured level of care, the burns—whether acute, subacute, eyelid in terms of its functional components, or chronic—receive echelon-appropriate evaluation malpositions, protraction, and retraction. Scar and treatment before the casualty is transported maturation followed by definitive surgical recon- to the next rearward echelon, where greater medi- struction occur in CONUS, where eye protection, cal expertise is available. At the 1st echelon, emer- then visual function, and finally cosmetic appear- gent care focuses on lifesaving ATLS and ACLS ance are addressed. principles and techniques and the immediate treat- At each echelon, casualties are reevaluated for ment of chemical burns. Urgent care focuses on evacuation, which is necessary for two reasons: (1) diagnosing ruptured globes and ocular injuries diminished vision makes the soldier nonfunctional and limiting the extent of thermal burn injuries. on the battlefield, and (2) extensive burns to the Management at higher echelons, where military eyelids are usually accompanied by serious injury ophthalmologists are found, always includes re- to the rest of the body, including the respiratory peating the steps from the lower echelons, not only passages. In general, only patients with first-degree to avoid the possibility of misdiagnosis and incom- and very mild second-degree burns are kept at the plete treatment of burns but also because the full lower echelons and returned to duty, and soldiers extent of eyelid burn wounds sometimes manifests with second- or third-degree burns to the eyelids over time. are evacuated back to CONUS.

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