Minor Care Series: Eyelid Lacerations

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Eyelid Anatomy 101

The eyelid is a thin but complex structure composed of many layers. Lacerations can range from only involving superficial thin skin to affecting eyelid function by injuring the orbicularis oculi muscle or levator palpebrae muscle.  The orbicularis oculi muscle fibers spread laterally through the eyelids and are responsible for eye closure.  The levator palpebrae muscle elevates the eyelid, “opening” the eyes.  There are also surrounding structures, such as the lacrimal system, which may be injured with eyelid trauma.  The lacrimal ducts and sac lie medially, adjacent to the medial canthus (see image).  With injuries to this area, suspect a lacrimal system injury. 

Figure 1. Eyelid Anatomy.  Courtesy of Wikimedia Commons (6).

Figure 2. Lacrimal Anatomy.  Courtesy of wikimedia commons (7).

How do we evaluate eyelid lacerations?

Figure 3. Lacrimal Anatomy. Courtesy of Wikimedia Commons (8).

Be suspicious and be systematic. Eyelid injuries are often associated with other serious trauma in and around the eye. Be mindful of the mechanism and do not forget to assess for other injuries with high morbidity and mortality.

Obtain a thorough history. How did the eyelid laceration occur? Was it a blunt or penetrating injury? an animal bite? Assault? Car accident? Certain mechanisms should create a higher suspicion for other injuries that may require early diagnosis or intervention.

Do not forget about the eyeball during evaluation. Obtain a visual acuity. Assess extraocular muscles for signs of entrapment. Use the slit lamp to look for hyphema and signs of globe rupture. Consider the chance that there could be corneal abrasions, foreign bodies or penetrating injury.

What are clues suggesting a complicated eyelid injury?

The findings in the table below suggest an eyelid injury that may require additional evaluation and repair. These clinical signs should prompt an ophthalmology consultation (1,2).

Table 1. Clinical findings in Complicated Eyelid lacerations. 

How do you repair an uncomplicated eyelid laceration?

The eyelid is a very thin structure and the eyeball is directly underneath it. Care must be taken to avoid iatrogenic globe rupture.

Anesthesia:  Local anesthesia with lidocaine with epinephrine can be used. Again, be careful to not puncture the globe. May also consider supraorbital or infraorbital nerve blocks.

Suture:  Non-absorbable sutures are the least inflammatory and have better aesthetic outcomes. 6-0 nylon sutures are a good choice. Simple interrupted sutures preferable in most cases. Can consider using a Morgan lens as barrier between needle and globe in appropriate cases.  If patient unlikely to follow up for suture removal, use vicryl or fast gut for closure.

Tetanus:  Review of tetanus indications (3):

Table 2. CDC Tetanus vaccination guidelines.

Antibiotics:  You may apply antibiotic ointment after repair. Superficial, uncomplicated lacerations do not require oral antibiotics. However, consider the mechanism and prescribe appropriate antibiotics if indicated.

Follow up:  Follow up with ophthalmology follow up in 5-7 days to assess healing process and for suture removal.

Learning Points:

  • Complicated eyelid lacerations are those with damage to the muscles involved in eyelid movement, violation of the orbital septum, concern for lacrimal system injury, or lacerations involving the lid margin.  Ophthalmology should be involved in all of these patients.
  • Uncomplicated lacerations should be closed with non-absorbable suture, no need for systemic antibiotics, update tetanus if needed, and follow up with ophthalmology in 5-7 days.
  • Do not forget to evaluate for corneal abrasion, intra-ocular muscle injury, and possible open globe.

Authored by James Li, MD

Posted by Tim Murphy, mD

References

  1. Clark TJE, Shriver EM. Emergent Evaluation of Eyelid Lacerations: A guide for ophthalmology residents. EyeRounds.org. December 17, 2015; Available from: http://www.EyeRounds.org/tutorials/eyelid-lacerations
  2. Lin, Brian. “Lacerations around the Eye.” Closing the Gap, 6 Apr. 2018, lacerationrepair.com/techniques/anatomic-regions/lacerations-around-the-eye/.
  3. “Tetanus.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 1 Sept. 2017, www.cdc.gov/tetanus/clinicians.html.
  4. Tintinalli, Judith E., et al. Tintinalli's Emergency Medicine: a Comprehensive Study Guide. McGraw-Hill Education, 2016.
  5. Walls, Ron M., et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. Elsevier, 2018.
  6. https://commons.wikimedia.org/wiki/File:Gray888.png
  7. https://commons.wikimedia.org/wiki/File:Sobo_1909_765.png
  8. https://commons.wikimedia.org/wiki/File:Gray896.png