Keywords

Eyelid lacerations; Canalicular lacerations; Trauma; Complications; Reconstruction

Introduction

Injury of the eyelid, either penetrating or blunt trauma, is a common medical condition that is often encountered in the emergency department and requires a well-planned and complex treatment to achieve good results and to reduce the possibility of postoperative complications [1].

Eyelid injuires, caused by various mechanisms such as accidents, sports injuires, bites, falls, assault, hitting while running, hooks, sticks, and vary from mild to severe, depending on the depth, location and involvement of the surrounding structures [2]. Some injuires may have tissue loss that distrups the normal anatomical condition of the eyelid [1,2].

In epidemiological studies involving eyelid traumas, it has been reported that the canalicular system is injured in approximately 16% of cases, and is more common in children and young adults [1-6]. While 72% of canalicular injuires occur in the lower canaliculi, 6-24% of them are bicanalicular system injuires [2,5,7]. Globe perforation may accompany in 20% of lacerations involving the canalicular system [5,8].

In order to prevent dysfunction, the factors leading to periocular injuires must be well quessionered and the eyelid anatomy must be well known [9,10]. The optimal time for repair should be within the first 48 hours following injury [2].

In canalicular injuires different surgical techniques, such as annular intubation with pig tail probe, bicanalicular or monocanalicular intubation can be used in order to ensure the integrity of the anastomosis site and prevent the development of stenosis [2,11]. In eyelid avulsion, the relatively weak posterior limb of the Medial Canthal Tendon (MCT) may be damaged and if not repaired properly, ectropion may developed [7,12]. If there is tissue lost grafting or advancement flaps are used.

In this study, we aimed to investigate the factors that cause eyelid or eyelid margin and canalicular system injuires with intact globe and the surgical outcomes.

Materials and Methods

In this retrospective study medical records of 80 patients who presented to our emergency department complaining about eyelid trauma from January 2017 to March 2021 were reviewed. The study protocol adhered to tenets of Declaration of Helsinki and was approved by the ethics committee. A fully informed written consent form to publish identifiable photograph archival was taken from all patients.

Details about the clinical history, mechanism and the occurrence time of injury, laterality, treatment, and surgical outcomes were analyzed. Ophthalmologic examination showed visual acuity of 20/20 in both eyes, normal ocular movements, mild conjunctival hyperaemia, clear cornea with negative fluorescein stain and normal anterior chamber with no inflammatory reaction. Funduscopic examination, pupil reflexes, and intraocular pressure were all normal.

Depending on the location of eyelid injuires, patients were classified into eyelid lacerations with or without involving the eyelid margin, injuires involving the medial cathal region and canaliculus, injuires related to levator muscle or aponeurosis, and injuires those with total eyelid avulsion. Patients with multiple lacerations in the forehead, eyelid injuires with globe perforation or eyelid injuires together with orbital fractures were not included in this study.

Patients were operated either local or general anaesthesia. The mean time from the first admission to the emergency room to the operation was 21.75 ± 15.09 hours. In cases with canalicular trauma medial lacerated end of the canaliculus was located under an operating microscope and repaired by using either annular intubation with pigtail probe or the monocanalicular intubation with Mini Monoka (FCI Ophthalmics, Marshfield Hill; MA) intracanalicular stents. Bicanalicular stent was used in cases with bicanalicular involvement. The pericanalicular tissue and associated medial cantal tendon injury was repaired with 7-0 polyglactin (Vicryl, Ethicon Inc., USA) interrupted sutures, followed by closure of muscle and skin. Lacerations involving the eyelid margin was repaired by simple closure. In cases where both anterior and posterior lamellae were absent, repair was performed using an advancement flap and free tarsal flap from the ipsilateral eyelid. In patients with levator aponeurosis injury, with orbital fat prolapsus, the prolapsed fat was repositioned and lid crease was performed as in ptosis surgery. The mean follow-up time was 8 ± 2.05 months. Patients were examined at the postoperative 1st day, were reviewed at 1 week, 1 month, and 3 month respectively. At each follow-up visits, the lacrimal punctum, position of the stent and ocular surface were evaluated. The stent was removed at postoperative 3rd month and the anatomical patency was checked with 27-gauge curved lacrimal irrigation cannula.

Results

There were 68 (85%) men and 12(15%) women, with a mean age of 29.58 ± 19.52 years (range; 1-78 years). The mean age of men was 28.72 ± 18.62, and women were 34.5 ± 23.41 years. 80 patients had unilateral lacerations, with equal eyelid involvement. Patients demographics were presented in Table 1.

Table 1: Demographic characteristics of patients and causes of eyelid trauma.

36(45%) of the patients had penetrating injuires with glass, stone, wire, scissors, hook, piece of iron and wood, dog bite, cat straching, 44 (55%) patients had blunt injuires with ball, door handle, hitting, falling, traffic, motor or bicycle accidents.

The classification of eyelid injuires according to age groups is shown in Table 2. Penetrating injuires were mostly seen between the ages of 26-45(25%), while blunt injuires were mostly between the ages of 1-15 (18.75%).

Table 2: The classification of eyelid injuries according to age groups.

Of the eyelid traumas, 31 (38.8%) were work-related injuires, 19(23.6%), were falling, 9(11.3%) were toy injuires, 7(8.8%) were homework injuires, 5(6.2%) were caused by traffic accidents, 5(6.2%) from fighting, 3(3.8%) from dog bites and 1(1.2%) from cat starching (Table 3). Work-related injuires were mostly caused by iron or wood, while home accidents were mostly caused by glass. Stone, ball and stick were responsible factors in game injuires.

Table 3: Etiologic factors in eyelid trauma.

Depending on the location of eyelid injuires, 25 (31.2%) had canalicular injury with eyelid margin lacerations, 34 (42.5%) had eyelid margin injury, 11(13.8%) had levator aponeurosis injuires, 10(12.5%) had total eyelid avulsion (Table 4). Pre and postoperatively eyelid injuires of the patients were shown in Figures 1A and 1B, Figures 2A and 2B and Figures 3A-3E.

Table 4: Classification of eyelid injuries according to site of the injuiry.

Figure 1: A- Injuiry with dog bite ( upper and lower lateral margin defect with orbital septum perforation and fat prolapsus, co-existing bicanalicular defect. B-Postoperative view of the same patient with primary closure of the wound, repair of the canaliculus with bicanalicular silicon entübation.

Figure 2: A-Canalicular injury with upper and lower ayelid defect due to falling. B-Advancement flap was used in upper nasal defecet, and tarsoconjunctival flap of the ipsilateral eyelid was used in the repair of lower defect. Mini Monaco tube was inserted. Transient mechanical ptosis was healed completely.

Figure 3: A-Full-thickness laceration of the upper and lower eyelid involving the eyebrow. Tissue loss appears evident on first glance because both the upper and lower lids are suspended on pedicle flaps everted laterally. B, C: Immediate peroperaative photograph shows re-approximation of tissue layers by primary closure, D: Peroperative view of the patient at the end of the operation. Avulsed tissues were well re-approximated and sutured with simple closureout, E: Postoperative first day view of the patient showing mild lid edema and mechanical ptosis.

20 (80%) of 25 patients with canalicular injuires were repaired with monocanalicular stent (Mini Monaco), and 5 (20%) were repaired by annular intubation using a pigtail probe.

Other related injuires included lateral cantal tendon injury in 3(3.75%) patients, and orbital septum prolapse in 7(8.8%) patients.

34(42.5%) of eyelid margin defect without tissue loss were repaired with simple closure. Tissue loss in 6 (7.5%) of 10 patients with eyelid avulsion was repaired with grafting and advancement flap.

Postoperative complications were traumatic telecantus in 5(6.6%) patients, traumatic ptosis in 2 (2.5%) patients, ectropion in 1 (1.3%) patient, pyogenic granuloma in 3(3.6%) patient, canalicular stenosis in 5(6.6%) patients. Spontaneous tube prolapse was seen in 3(3.6%) patients. None of our patients developed lid margin notching, lagophthalmos, hypertrophic scar, or infection (Table 5).

Table 5: Postoperative complications.

Discussion

Injures to the periocular region are often complex and involve more than one anatomical structure [13]. With a well-planned approach, it is possible to reduce the possibility of postoperative complications and to achieve good functional and cosmetic results [14]. Firstly a detailed history should be taken to determine the source of injury. Blunt trauma can cause tissue edema. Patients with lid trauma must be examined for both nerve and muscle function [10].

Men are more prone to trauma at a rate of 70-86.5% and mostly occurs between the ages of 5-25 and over the age of 70 [15]. In one study, it was stated that 85% of eye traumas occurred as a result of penetrating injuires, and in another study, this rate was given as 77.7% for blunt trauma and 22.2% for penetrating trauma. It was also stated that 20% of eyelid injuires were work- related, 25.3% were home-garden accidents and 20% were game accidents [4,15-17]. In another study, these rates were reported as 36.6% work-related injuires and 21.1% injuires due to falling [4,15].

In our study, 68(85%) of patients exposed to trauma were men. Penetrating injury due to any of the reasons such as glass, stone, wire, scissors, hook, iron or wood piece, dog bite, cat strach was present in 45% of the cases and was mostly seen between the ages of 26-45. Blunt injuires from hitting a ball or door handle, falling while running or walking, or falling out of bed, which is more common in young children, or injuires from traffic, motor or bicycle accidents were mostly between the ages of 1-15.

Of the eyelid traumas, the most common responsible factor in our patients was work-related injuires with a rate of 38.5%. The high rate of work-related injury in men is due to excess number of them were working in the heavy industrial area, and their reluctance to use protective equipment while working. Apart from this, the heavy living conditions make people very aggressive and prone to violence. Eyelid injury as a result of falling was the second most common factor with a rate of 23.8%, and was mostly occurred during play or falling out of bed in children, and in elderly, falling while walking due to systemic diseases such as atherosclerosis, hypertension, and dementia. Home accidents with a rate of 6.2% were mostly occurred in women with glass. 11.3% of our patients were injuried with toys, 6.2% injuried in traffic accidents and 3.8% were injuried by dog bite.

The duration of admission to the emergency service after trauma was reported as 6.8-42.4 hours and the mean time between the arrival to hospital and surgery was reported as 3.5 to 12.9 hours. [15,17] The long duration of this period was attributed to intense periorbital edema, which prevents the operation under elective conditions [15]. In our study, due to the proximity of our hospital to the industrial center and the main road, it was possible for patients to reach the hospital within 1 to 4 hours after injury and to be operated within 24 to 48 hours.

Eyelid traumas may be accompanied by other ocular pathologies such as canalicular injury, eyelid edema, ecchymosis, penetrating eye injuires, lens damage, subconjunctival haemorrhage, and conjunctival laceration, foreing body in the eye, retinal tear, and detachment [15]. When laceration occurs medial to the punctum, all but the most superficial injuires will transect the canaliculus [14]. Canalicular laceration has been reported in all age groups, and reported as 30.2% [15,18,19]. Probing and irrigation of questionable injuires should ideally be done without local anaesthesia because tissue edema may lead to false-positive results [14]. If the eyelid-laceration is repaired without paying attention to the canalicular system, it will result in canalicular occlusion [18]. Different surgical techniques have been described for the treatment of canalicular tears. The use of a pigtail probe has not been a very popular method due to poor surgical results, the risk of trauma to the unaffected canaliculus, and the more challenging technique [18]. Silicone has been the material of choice for stenting, and a good success rate have been reported with Crawford intubation system [18,19]. On the other hand, bicanalicular nasal intubation may require surgical experience and special instruments to retrieve the silicone tubes from nasal cavity [4-5]. This has also been reported to give rise to several complications including punctual or canalicular slitting, granuloma formation, superior loop dislocation, and chronic nasal irritation [5, 20-22].

In our study, 31.2% of the patients had canalicular injuires, of which 23.8% lower, 5% upper, and 2.5% bicanalicular injury. We performed annular intubation with a pigtail probe in our first cases, but the following years we began to use monocanalicular intubation. Traumatic telecantus and canaliculi stenosis occurred in our first cases that we repaired with pigtail probe. The Mini Monaco tube prevents both the formation of lid contour deformity and the development of stenosis in the canaliculus, and lacrimal irrigation was also positive in this group. As tube- related complications, 3(3.6%) patients had pyogenic granuloma, was simply excised. Follow-up was recommended for epiphora complaints in 5(6.6%) patients whose canaliculi damage was repaired with pigtail probe, but stenosis developed. Lacrimal irrigation was positive in 3(3.6%) patients with spontaneous tube prolapsed in the 1st month postoperatively, and stenosis did not develop.

Traumatic ptosis may occur as a complication due to direct or indirect eyelid trauma, levator disinsertion or third nerve injury [14]. This is a mechanical ptosis caused by hematoma or tissue edema, which usually resolves with time, but secondary stretching or tearing of the levator aponeurosis can cause permanent ptosis [14]. Especially in the pediatric age group, traumatic ptosis should be carefully monitored for the risk of ambliyopia [14]. Penetrating injuires may directly damage the levator’s nerve supply, and blunt head trauma can result in neurogenic ptosis. Six months should be allowed to pass before undertaking surgery in such instances because spontaneous recovery may occur [14]. It is stated that orbital fat prolapse in horizontal eyelid injuires indicates injury to the levator aponeurosis, and if the prolapsed fat is small it can be repositioned behind the septum, but if it is prolapsed freely, it should be excised in order to reduce the risk of infection because of its insufficient vascularization [14]. In our study, no complication developed after the repair of 7 (8.8%) patients who had horizontal eyelid injury with orbital fat prolapse by preserving the normal anatomy. However, in one of our patients with total eyelid avulsion and fat prolapsus, cicatricial ectropion was developed. We think that it is due to the tension effect while suturing the septum.

In our study we had 4 patients with yelid defect in the upper medial part of the eyelid and lower nasal tarsal conjunctiva. We used advancement flap and free tarsoconjuctival graft in the closure of the eyelid defect. On the 1st postoperative day, edema, ecchymosis, chemosis and ptosis were present. This mechanical ptosis resolved completely at the 3rd month postoperatively. As care was taken not to create tension in the tissue during the repair of the injuried eyelid, a smooth eyelid contour was obtained without any notching, kinking, and trichiasis, and no further reconstruction was required.

It is mentioned that full-thickness lacerations that do not involve the eyelid margin are usually rare, and in the treatment of this type of injuires, the skin is usually closed with or without separate closure of orbicularis muscle. If the tarsal integrity is compromised in injuires s involving the eyelid margin, the tarsus should be carefully re-approximated to avoid notching, kinking, and trichiasis [14]. In cases where direct closure is impossible, advancement flaps, such as an aperiostal flap or Tenzel semicircular rotational flaps can be created. However, in elderly individuals with loose eyelids, even 10% to 15% larger defects can be closed directly [23]. In our study, eyelid injuires in which the canalicular system was intact, the injuried parts were closed primarily, or if there was tissue loss, grafting and advancement flaps were used in the treatment. Tissue loss in 3 patients with lateral eyelid tissue loss defect and perforated orbital septum due to dog bite was successfully repaired with advancement flap.

Conclusion

Eyelid traumas, which are mostly treated in the emergency room, are extremely important due to anatomical and functional disorders such as eyelid deformity, ocular surface disorder, and cosmetic problems. For this reason, it is important to know the factors that cause trauma, to determine the location, size and depth of the injury, and to evaluate whether there is tissue loss. Trauma especially involving the eyelid rim, canalicular system or levator muscle, should be repaired by the ophthalmologist and patients should be well informed about risks and possible sequela.

References

1. Hawlina G, Vergot K (2019). Management of Traumatic Lower-Eyelid Avulsion and Complete Loss of the Lacrimal Canaliculus: A Case Report. Case Rep Ophthalmol.10:172-179.
2. Gordon AA, Tran LT, Phelps PO (2020) Eyelid and orbital trauma for the primary care physician. Dis Mon.66: 101045.
3. Singh M, Gautam N, Ahir N, Kaur M (2017) Is the distance from punctum a factor in the anatomical and functional success of canalicular laceration repairs? Indian J Ophthalmol. 65: 1114-1119.
4. Herzum H, Holle P, Hintschich C (2001) Lidverletzungen epidemiologische aspekte. Ophthalmologe. 98:1079-1082.
5. Naik MN, Kelapure A, Rath S, Honavar SG (2008) Management of canalicular lacerations: epidemiological aspects and experience with Mini-Monoka monocanalicular stent. Am J Ophthalmol.145:375-380.
6. Nairing Tint NL, Alexander P, Cook AE, Leatherbarrow B (2011). Eyelid avulsion repair with bi-canalicular silicone stenting without medial canthal tendon reconstruction. Br J Ophthalmol. 95:1389-1392.
7. Kennedy RH, May J, Dailey J, Flanagan JC (1990). Canalicular laceration. An 11-year epidemiologic and clinical study. Ophthalmic Plast Reconstr Surg.6:46-53
8. Fayet B, Bernard JA, Ammar J, Karpouzas Y, Hamici S (1988). Contribution à l'étude des plaies récentes des voies lacrymales: à propos de 262 cas traités en urgence. J Fr Ophtalmol.11:627-637.
9. Murchison AP, Bilyk JR. Management of eyelid injuries(2010). Facial Plast Surg. 26:464-481.
10. Nelson CC. Management of eyelid trauma (1991). Aust N Z J Ophthalmol.19:357-363.
11. Reifler DM (1991). Management of canalicular laceration. Surv Ophthalmol.36:113-132.
12. Zide BM, McCarthy JG (1983). The medial canthus revisited-an anatomical basis for canthopexy. Ann Plast Surg.11:1-9.
13. Ko AC, Satterfield KR, Korn BS, Kikkawa DO (2021) Eyelid and periorbital soft tissue trauma. Oral Maxillofac Surg Clin North Am.33:317-328.
14. Beadles KA, Lessner AM (1994). Management of traumatic eyelid lacerations. Semin Ophthalmol.9:145-151.
15. Elif B türkoÄ?lu, Tök L, Tök ÖY,Dikici S,KocaoÄ?lu FA, et al. (2014). Göz kapaÄ?ı yaralanması ile birlikte olan oküler travmaların epidemiyolojik yönden incelenmesi. MN Oftalmoloji. 21:56-62.
16. Ortak H, Erbil HH (2010) Perforan göz yaralanmalarının epidemiyolojik deÄ?erlendirilmesi. Tıp AraÅ?tırmaları Dergisi. 8:150-155.
17. KarslıoÄ?lu Å?, HacıbekiroÄ?lu A, Tamsel Å?, TümÅ?en D, Ziylan Å?, et al. (2001). Göz travmalarının epidemiyolojik yönden incelenmesi. Turk J Ophthalmol. 31:484-491.
18. Maheshwari RD, Maheshwari M (2020) Annular intubation with pigtail probe for canalicular lacerations.Indian Journal of Ophthalmology.68:2166-2169.
19. Tint NL, Alexander P, Cook AE, Leatherbrow B (2011). Eyelid avulsion repair with bi-canalicular silicone stenting without medial canthal tendon reconstruction. Br J Ophthalmol.95:1389-1392.
20. Reifler DM (1991). Management of canalicular laceration. Surv Ophthalmol.36:113–132.
21. Dresner SC, Codère F, Brownstein S, Jouve P (1984). Lacrimal drainage system inflammatory masses from retained silicone tubing. Am J Ophthalmol.98:609-613.
22. Lauring L (1976). Silicone intubation of the lacrimal system: pitfalls, problems and complications. Ann Ophthalmol. 8:489-498.
23. Tenzel RR, steward WB (1978). Eyelid reconstruction by semi-circular flap technique. Trans Am Soc Ophthalmol Otolaryngol.85:1164-1169.