Ocular Injury and Emergencies Around the Globe



Ocular Injury and Emergencies Around the Globe




Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2021-03-01, Volume 29, Issue 1, Pages 19-28, Copyright © 2020 Elsevier Inc.



Key points

  • Retrobulbar hemorrhage in the setting of orbital trauma can cause orbital compartment syndrome, which may result in irreversible vision loss. Immediate action through a lateral canthotomy and cantholysis is required.

  • Ocular examination should be performed by an ophthalmologist in any case of periocular trauma. If globe laceration is suspected, any manipulation of the area should be avoided until integrity of the globe has been confirmed or sufficiently restored.

  • Adequate knowledge of the anatomy and functional and dynamic behavior of the eyelids is paramount when performing repair of an eyelid laceration.

  • Repair of canalicular lacerations should be attempted in all cases within 48 hours by a surgeon experienced in lacrimal surgery.


Introduction

The orbital soft tissues include various important structures such as the eyelids, lacrimal drainage system, extraocular muscles, the optic nerve, and the globe. Although protected by the bony orbit, these structures are prone to traumatic injuries which, as discussed in this chapter, include orbital compartment syndrome, globe laceration, eyelid laceration, and damage to the lacrimal drainage system. It is paramount that such injury is timely recognized and adequately dealt with, and a thorough examination should therefore be performed by an ophthalmologist in any case of orbital trauma. However, because of the multidisciplinary nature of the orbital region, it is important that other physicians also are familiar with these injuries.


Retrobulbar hemorrhage and orbital compartment syndrome


Etiology and clinical assessment

The intraorbital structures are confined within a closed and rigid compartment consisting of the bony orbital walls and the orbital septa and eyelids ( Box 1 ). As such, there is little space to accommodate a sudden increase in orbital pressure. Orbital compartment syndrome (OCS) occurs when the intraorbital pressure exceeds the arterial perfusion pressure, resulting in ischemia and irreversible damage to the optic nerve and retina within 100 minutes. The most common cause of such an increase in orbital pressure is retrobulbar hemorrhage, as may occur in the setting of periocular trauma.

Box 1
Signs of orbital compartment syndrome

  • Progressive proptosis

  • Decreased visual acuity

  • Relative afferent pupillary defect (RAPD)

  • Concentric motility impairment

  • Pain

  • Increased intraocular pressure

  • Tight orbital tissues

  • Chemosis

  • Decreased retinal perfusion, as noted on fundoscopy


Treatment: lateral canthotomy and cantholysis

In line with the previously mentioned etiology, emergency treatment is directed at opening up the closed compartment. This is accomplished in the first place by performing a lateral canthotomy and cantholysis, a technique that any emergency physician or medical specialist involved in the orbital region should be familiar with. The canthal ligaments (sometimes referred to as tendons) are the structures that attach the eyelid tarsi to the bony orbit, with the lateral ligament being the most easily accessible. Releasing the eyelid from its attachment to the lateral orbital wall opens up the orbital compartment and allows for an anterior movement of the globe, thereby decreasing the intraorbital pressure. Sometimes the question is raised whether this anterior movement of the globe does not stretch the optic nerve, causing permanent damage as well. However, the length of the orbital part of the optic nerve is somewhat redundant, allowing for some degree of exophthalmos before the nerve fibers are put on stretch. Even more so, tensile forces on the optic nerve are far less harmful than ischemia.

Lateral canthotomy and cantholysis is performed as follows:

  • Canthotomy ( Fig. 1 A): Use scissors to make a cut in the lateral canthal angle, directed away from the globe, up to the lateral orbital rim. The cut is made through all layers of the lateral canthal angle at once: skin, orbicularis muscle, lateral canthal ligament, palpebral conjunctiva. Make sure not to cut the bulbar conjunctiva, as this may cause symblepharon. This first cut effectively divides the lateral canthal ligament into an inferior and superior limb.

    Technique for lateral canthotomy and inferior cantholysis. ( A ) Lateral canthotomy. ( B ) Dissection of a skin-muscle flap. ( C ) Inferior cantholysis.
    Fig. 1
    Technique for lateral canthotomy and inferior cantholysis. (
    A ) Lateral canthotomy. (
    B ) Dissection of a skin-muscle flap. (
    C ) Inferior cantholysis.

  • Skin-muscle flap ( Fig. 1 B): By blunt dissection, you can now create a skin-muscle flap inferior to the lateral canthal angle.

  • Inferior cantholysis ( Fig. 1 C): When you raise the skin-muscle flap, the underlying inferior limb of the lateral canthal ligament is exposed, but often not clearly distinguishable. With tooth forceps, grasp the eyelid margin of the lower eyelid near the lateral canthal angle and pull the eyelid medially and anteriorly. By doing so, the inferior limb of the lateral canthal ligament is put on stretch. With the tip of the closed scissors you can now feel the inferior limb of the canthal ligament as a tight string. Open up the scissors around this string and cut it with your scissors directed directly inferior. Again, feel with your scissors for residual attachments and cut them. Repeat this until the cantholysis is completed and the eyelid is freely mobile. Note that the lateral canthal ligament is continuous with fibers from the orbital septum. Therefore, the cut may need to be extended to include the septum to acquire adequate mobility.

  • Superior cantholysis: If you feel that inferior cantholysis has yielded insufficient release of the compartment syndrome, superior cantholysis can be performed in a similar fashion. It is advisable to direct this cut superiorly as well as slightly laterally to avoid cutting into the lacrimal gland, which may cause brisk bleeding and can result in severe dry eye.

  • Repair of the lateral canthal angle: After approximately 2 weeks, the canthal angle can be closed; however, in most cases, repair is not necessary, as spontaneous granulation usually provides adequate results.

It should be noted that in the setting of an orbital fracture (mostly the floor or medial wall), the compartment may have been opened up sufficiently by the fracture itself and cantholysis may not be necessary. However, OCS still can occur if the periorbita remains intact. Conversely, if inferior and superior cantholysis have been performed without the desired effect, emergency orbital decompression, including opening of the periorbita, must be considered.


Orbital compartment syndrome and imaging

The indication for imaging in the context of OCS, as well as the precise indications to perform cantholysis, are source of debate. We advise the following rules of thumb:

  • Do not delay treatment awaiting radiological evaluation:The decision to perform inferior cantholysis should be made based on clinical signs, not solely on the findings of computed tomography (CT) imaging. Although a retrobulbar hemorrhage can be easily seen on CT imaging, the urgency of the situation dictates to act immediately when OCS is suspected, without delay for radiological evaluation. Conversely, a small retrobulbar hemorrhage that is noted on CT imaging without clinical manifestations of OCS may be left untreated.

  • When in doubt, make the cut: Remember that not performing a cantholysis when you should have done so, may result in permanent and profound loss of vision. On the other hand, an adequately executed, inferior cantholysis rarely causes permanent complaints after healing.


Trauma to the globe


Ocular examination

It is important to remember that damage to the intraocular structures can occur even in apparently mild cases of trauma, and thorough ocular examination should therefore be performed by an ophthalmologist in any case of periocular trauma. The first assessment, however, can be performed by the emergency physician ( Box 2 ). We believe that the ophthalmologist should be involved directly in the emergency room in any of the circumstances, as listed in Box 3 . In any other case, more detailed examination by an ophthalmologist can be performed within the next few days.

Box 2
Ocular assessment by emergency physician

  • Confirm integrity of the globe

  • Visual acuity

  • Red cap test

  • Confrontational visual field

  • Ocular Motility

  • Pupillary test, including RAPD

Box 3
Indications for ocular assessment by an ophthalmologist

  • Suspected intraorbital hemorrhage

  • Suspected globe laceration

  • Suspected extraocular muscle entrapment

  • Exophthalmos or tenting of the optic nerve

  • Eyelid and/or lacrimal lacerations

  • Decreased vision

  • Unconscious patients


Globe laceration

Laceration of the globe can occur in penetrating or blunt periocular trauma and accordingly should be ruled out in all cases of periocular trauma. Signs of globe laceration are listed in Box 4 .

Box 4
Signs of globe laceration

  • Prolapse of uvea, vitreous, or retina ( Fig. 2 )

  • Intraocular foreign body (as noted on biomicroscopy/fundoscopy or orbital imaging)

  • Orbital imaging suggestive of globe laceration

  • Leakage of intraocular fluids as demonstrated by a positive Seidel test

  • History of sharp periocular trauma

  • Eyelid laceration

  • Extensive subconjunctival hemorrhage

  • Peaked pupil (see Fig. 2 )

  • Shallow anterior chamber

  • Hypotony

Small globe laceration at the level of the limbus. Note the peaked pupil pointing toward the location of the uveal prolapse.
Fig. 2
Small globe laceration at the level of the limbus. Note the peaked pupil pointing toward the location of the uveal prolapse.

If a globe laceration is indeed suspected, the following should be initiated:

  • Place a protective shield (not a pressure bandage!)

  • Ask the ophthalmologist for urgent consultation

  • Make sure the patient is kept on a nil per os regimen

  • Provide with adequate systemic analgesics

  • Avoid any manipulation of the globe and eyelids:

    • Do not administer topical medication unless necessary

    • Provide with adequate sedatives in case of anxiety

    • Provide with adequate antiemetics, as vomiting may give increased pressure on the globe

    • If possible, postpone examination or treatment of other injuries until integrity of the globe has been confirmed or sufficiently restored by an ophthalmologist.


Other traumatic ocular injury

Although a detailed description is beyond the scope of this article, other complications of ocular trauma are listed in Box 5 .

Box 5
Other complications of ocular injury

  • Corneal erosion

  • Hyphema ( Fig. 3 )

  • Iridodialysis ( Fig. 4 )

  • Cataract

  • Lens luxation ( Fig. 5 )

  • Vitreous hemorrhage

  • Commotio retinae

  • Choroidal rupture

  • Retinal breaks and detachment

  • Traumatic optic neuropathy

  • Optic nerve avulsion

Hyphema.
Fig. 3
Hyphema.

Iridodialysis.
Fig. 4
Iridodialysis.

Lens luxation.
Fig. 5
Lens luxation.


Eyelid lacerations


Eyelid lacerations not involving the eyelid margin

Although repair of eyelid lacerations that do not involve the eyelid margin may seem relatively straightforward, adequate knowledge of the anatomy and dynamic behavior of the eyelids is paramount to reduce the risk of complications. We recommend the following principles:

  • Always confirm integrity of the globe: The eyelids are only thin protection of the globe. Therefore, an eyelid laceration should always prompt assessment of the globe’s integrity.

  • Conservative wound debridement: Parts of the skin that are unviable can be removed by wound debridement; however, vascularization of the eyelids is excellent, so that debridement usually does not have to be performed aggressively. Moreover, remember that excessive debridement may lead to a relative skin deficiency, which may cause cicatricial ectropion or lagophthalmos. Free, relatively clean, avascularized flaps may be sutured back in their anatomic location.

  • Do not close the orbital septum: The orbital septum is a sheet of fibrous tissue that extends from the orbital rims to fuse with the eyelid retractors. If the orbital septum is violated in an eyelid laceration, closing of the septal defect is not advisable, as this may lead to shortening of the septum. As the septum is a rigid structure firmly attached to the orbital rim, shortening may lead to a hang up of the eyelid causing lagophthalmos and exposure of the globe.


Eyelid lacerations involving the eyelid margin

It is important to understand that the eyelid margin is crucial for both functional and esthetic aspects of the eyelid and adequate restoration of eyelid margin is paramount. Various suture techniques have been described. For all techniques, good functional and esthetic results are obtained only if the following rules are followed:

  • Protect the globe: Working closely to the ocular surface, it is advisable to protect the globe with either a protective shield or Jäger plate.

  • Do not pass through the conjunctiva: In any technique for eyelid closure, care is taken not to breach the conjunctiva because the suture may cause irritation to the ocular surface, resulting in corneal abrasion or even ulcers. Also, place the knot anteriorly so that it does not erode through the conjunctiva.

  • Mirror the sutures: The sutures are “mirrored,” both in an anterior-posterior and superior-inferior direction. This means that the height and depth of the suture should be exactly equal on both sides of the wound. If this is not done properly, a notch in the eyelid margin will result ( Fig. 6 ).

    Laceration of the eyelid margin. ( A ) Traumatic laceration of the central inferior eyelid involving the eyelid margin. ( B ) Small notch after repair.
    Fig. 6
    Laceration of the eyelid margin. (
    A ) Traumatic laceration of the central inferior eyelid involving the eyelid margin. (
    B ) Small notch after repair.

  • If unsatisfied, try again: It is easier to obtain adequate eyelid position during the primary repair than to do so at a later stage. Therefore, if you feel that the wound margins do not approximate nicely, remove the sutures and try again.

  • Timing: Primary closure of eyelid laceration is preferably performed within 24 hours, although we believe that good results can be obtained up to 48 hours.

Most surgeons use a double-layered suture technique, which consists of deep tarsal sutures together with superficial skin sutures. Although many techniques are described, we usually use the following:

  • Deep tarsal sutures ( Fig. 7 A): Just inferior to the eyelid margin, a Vicryl 6-0 or 5-0 suture is passed into the orbicularis muscle and out through the underlying tarsus. In the opposite wound edge, the suture is then passed through the tarsus and back out through the overlying orbicularis muscle. As noted previously, the height and depth of these passes should be exactly mirrored so that the wound edges approximate correctly. By pulling each end to the opposing side, you can confirm that the position of the suture is adequate. Now, before tying the first suture, a second suture is placed in a similar fashion just 2 to 3 mm inferiorly. If necessary, another third suture can be placed, again 2 to 3 mm inferiorly. The first suture is now tied. This often results in an angled apposition of the wound edges, which is corrected by tying the second and possibly third suture. Note that only 2 or 3 of these sutures are needed in the lower eyelid, whereas usually 3 or 4 are needed for closure of the upper eyelid, as it has a much higher tarsal plate.

    Closure of an eyelid margin defect in 2 layers. ( A ) Placement of the deep tarsal sutures ( purple ) and eyelid margin suture ( blue ). ( B ) The eyelid margin suture is left long and tied down with the skin sutures.
    Fig. 7
    Closure of an eyelid margin defect in 2 layers. (
    A ) Placement of the deep tarsal sutures (
    purple ) and eyelid margin suture (
    blue ). (
    B ) The eyelid margin suture is left long and tied down with the skin sutures.

  • Eyelid margin suture ( Fig. 7 B): Although the deep tarsal sutures are the most important for reconstruction and integrity of the eyelid margin, a subtle indentation at the level of the gray line may remain. Therefore, some surgeons prefer to place an additional 6-0 or 7-0 fast-absorbing suture through the gray line. Because of its proximity to the ocular surface, this suture may cause irritation. To prevent this, the ends of the suture are usually left long and will be tied down with the skin sutures.

  • Skin sutures (see Fig. 7 B): Either nonabsorbable sutures such as Prolene 6-0 or fast-absorbing sutures such as Vicryl Rapide 6-0 are used to close the skin. As mentioned, these sutures can be used to tie down the ends of the eyelid margin suture.

Although variations of the previously mentioned double-layered suture technique have been used historically, a single-layered technique can give similar results :

  • Single-layered suture for skin, orbicularis muscle and tarsus ( Fig. 8 A): Just inferior to the eyelid margin, a Prolene or Vicryl 6-0 is passed through skin and orbicularis muscle and exits through the underlying tarsus. In the opposing wound edge, the suture is then passed through the tarsus and back out through the overlying orbicularis muscle and skin. Again, before tying this suture, a second suture is placed in a similar manner 2 to 3 mm inferiorly.

    Closure of an eyelid margin defect in one layer. ( A ) Single-layered suture for skin, orbicularis muscle, and tarsus. ( B ) An additional eyelid margin suture can be placed if needed, but is not shown here.
    Fig. 8
    Closure of an eyelid margin defect in one layer. (
    A ) Single-layered suture for skin, orbicularis muscle, and tarsus. (
    B ) An additional eyelid margin suture can be placed if needed, but is not shown here.

  • Eyelid margin suture ( Fig. 8 B): If needed, an additional eyelid margin suture can be placed and tied down with the other sutures.


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Ocular Injury and Emergencies Around the Globe Gijsbert J. Hötte MD and Ronald O.B. De Keizer MD Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 2021-03-01, Volume 29, Issue 1, Pages 19-28, Copyright © 2020 Elsevier Inc. Key points Retrobulbar hemorrhage in the setting of orbital trauma can cause orbital compartment syndrome, which may result in irreversible vision loss. Immediate action through a lateral canthotomy and cantholysis is required. Ocular examination should be performed by an ophthalmologist in any case of periocular trauma. If globe laceration is suspected, any manipulation of the area should be avoided until integrity of the globe has been confirmed or sufficiently restored. Adequate knowledge of the anatomy and functional and dynamic behavior of the eyelids is paramount when performing repair of an eyelid laceration. Repair of canalicular lacerations should be attempted in all cases within 48 hours by a surgeon experienced in lacrimal surgery. Introduction The orbital soft tissues include various important structures such as the eyelids, lacrimal drainage system, extraocular muscles, the optic nerve, and the globe. Although protected by the bony orbit, these structures are prone to traumatic injuries which, as discussed in this chapter, include orbital compartment syndrome, globe laceration, eyelid laceration, and damage to the lacrimal drainage system. It is paramount that such injury is timely recognized and adequately dealt with, and a thorough examination should therefore be performed by an ophthalmologist in any case of orbital trauma. However, because of the multidisciplinary nature of the orbital region, it is important that other physicians also are familiar with these injuries. Retrobulbar hemorrhage and orbital compartment syndrome Etiology and clinical assessment The intraorbital structures are confined within a closed and rigid compartment consisting of the bony orbital walls and the orbital septa and eyelids ( Box 1 ). As such, there is little space to accommodate a sudden increase in orbital pressure. Orbital compartment syndrome (OCS) occurs when the intraorbital pressure exceeds the arterial perfusion pressure, resulting in ischemia and irreversible damage to the optic nerve and retina within 100 minutes. The most common cause of such an increase in orbital pressure is retrobulbar hemorrhage, as may occur in the setting of periocular trauma. Box 1 Signs of orbital compartment syndrome Progressive proptosis Decreased visual acuity Relative afferent pupillary defect (RAPD) Concentric motility impairment Pain Increased intraocular pressure Tight orbital tissues Chemosis Decreased retinal perfusion, as noted on fundoscopy Treatment: lateral canthotomy and cantholysis In line with the previously mentioned etiology, emergency treatment is directed at opening up the closed compartment. This is accomplished in the first place by performing a lateral canthotomy and cantholysis, a technique that any emergency physician or medical specialist involved in the orbital region should be familiar with. The canthal ligaments (sometimes referred to as tendons) are the structures that attach the eyelid tarsi to the bony orbit, with the lateral ligament being the most easily accessible. Releasing the eyelid from its attachment to the lateral orbital wall opens up the orbital compartment and allows for an anterior movement of the globe, thereby decreasing the intraorbital pressure. Sometimes the question is raised whether this anterior movement of the globe does not stretch the optic nerve, causing permanent damage as well. However, the length of the orbital part of the optic nerve is somewhat redundant, allowing for some degree of exophthalmos before the nerve fibers are put on stretch. Even more so, tensile forces on the optic nerve are far less harmful than ischemia. Lateral canthotomy and cantholysis is performed as follows: Canthotomy ( Fig. 1 A): Use scissors to make a cut in the lateral canthal angle, directed away from the globe, up to the lateral orbital rim. The cut is made through all layers of the lateral canthal angle at once: skin, orbicularis muscle, lateral canthal ligament, palpebral conjunctiva. Make sure not to cut the bulbar conjunctiva, as this may cause symblepharon. This first cut effectively divides the lateral canthal ligament into an inferior and superior limb. Fig. 1 Technique for lateral canthotomy and inferior cantholysis. ( A ) Lateral canthotomy. ( B ) Dissection of a skin-muscle flap. ( C ) Inferior cantholysis. Skin-muscle flap ( Fig. 1 B): By blunt dissection, you can now create a skin-muscle flap inferior to the lateral canthal angle. Inferior cantholysis ( Fig. 1 C): When you raise the skin-muscle flap, the underlying inferior limb of the lateral canthal ligament is exposed, but often not clearly distinguishable. With tooth forceps, grasp the eyelid margin of the lower eyelid near the lateral canthal angle and pull the eyelid medially and anteriorly. By doing so, the inferior limb of the lateral canthal ligament is put on stretch. With the tip of the closed scissors you can now feel the inferior limb of the canthal ligament as a tight string. Open up the scissors around this string and cut it with your scissors directed directly inferior. Again, feel with your scissors for residual attachments and cut them. Repeat this until the cantholysis is completed and the eyelid is freely mobile. Note that the lateral canthal ligament is continuous with fibers from the orbital septum. Therefore, the cut may need to be extended to include the septum to acquire adequate mobility. Superior cantholysis: If you feel that inferior cantholysis has yielded insufficient release of the compartment syndrome, superior cantholysis can be performed in a similar fashion. It is advisable to direct this cut superiorly as well as slightly laterally to avoid cutting into the lacrimal gland, which may cause brisk bleeding and can result in severe dry eye. Repair of the lateral canthal angle: After approximately 2 weeks, the canthal angle can be closed; however, in most cases, repair is not necessary, as spontaneous granulation usually provides adequate results. It should be noted that in the setting of an orbital fracture (mostly the floor or medial wall), the compartment may have been opened up sufficiently by the fracture itself and cantholysis may not be necessary. However, OCS still can occur if the periorbita remains intact. Conversely, if inferior and superior cantholysis have been performed without the desired effect, emergency orbital decompression, including opening of the periorbita, must be considered. Orbital compartment syndrome and imaging The indication for imaging in the context of OCS, as well as the precise indications to perform cantholysis, are source of debate. We advise the following rules of thumb: Do not delay treatment awaiting radiological evaluation:The decision to perform inferior cantholysis should be made based on clinical signs, not solely on the findings of computed tomography (CT) imaging. Although a retrobulbar hemorrhage can be easily seen on CT imaging, the urgency of the situation dictates to act immediately when OCS is suspected, without delay for radiological evaluation. Conversely, a small retrobulbar hemorrhage that is noted on CT imaging without clinical manifestations of OCS may be left untreated. When in doubt, make the cut: Remember that not performing a cantholysis when you should have done so, may result in permanent and profound loss of vision. On the other hand, an adequately executed, inferior cantholysis rarely causes permanent complaints after healing. Trauma to the globe Ocular examination It is important to remember that damage to the intraocular structures can occur even in apparently mild cases of trauma, and thorough ocular examination should therefore be performed by an ophthalmologist in any case of periocular trauma. The first assessment, however, can be performed by the emergency physician ( Box 2 ). We believe that the ophthalmologist should be involved directly in the emergency room in any of the circumstances, as listed in Box 3 . In any other case, more detailed examination by an ophthalmologist can be performed within the next few days. Box 2 Ocular assessment by emergency physician Confirm integrity of the globe Visual acuity Red cap test Confrontational visual field Ocular Motility Pupillary test, including RAPD Box 3 Indications for ocular assessment by an ophthalmologist Suspected intraorbital hemorrhage Suspected globe laceration Suspected extraocular muscle entrapment Exophthalmos or tenting of the optic nerve Eyelid and/or lacrimal lacerations Decreased vision Unconscious patients Globe laceration Laceration of the globe can occur in penetrating or blunt periocular trauma and accordingly should be ruled out in all cases of periocular trauma. Signs of globe laceration are listed in Box 4 . Box 4 Signs of globe laceration Prolapse of uvea, vitreous, or retina ( Fig. 2 ) Intraocular foreign body (as noted on biomicroscopy/fundoscopy or orbital imaging) Orbital imaging suggestive of globe laceration Leakage of intraocular fluids as demonstrated by a positive Seidel test History of sharp periocular trauma Eyelid laceration Extensive subconjunctival hemorrhage Peaked pupil (see Fig. 2 ) Shallow anterior chamber Hypotony Fig. 2 Small globe laceration at the level of the limbus. Note the peaked pupil pointing toward the location of the uveal prolapse. If a globe laceration is indeed suspected, the following should be initiated: Place a protective shield (not a pressure bandage!) Ask the ophthalmologist for urgent consultation Make sure the patient is kept on a nil per os regimen Provide with adequate systemic analgesics Avoid any manipulation of the globe and eyelids: ○ Do not administer topical medication unless necessary ○ Provide with adequate sedatives in case of anxiety ○ Provide with adequate antiemetics, as vomiting may give increased pressure on the globe ○ If possible, postpone examination or treatment of other injuries until integrity of the globe has been confirmed or sufficiently restored by an ophthalmologist. Other traumatic ocular injury Although a detailed description is beyond the scope of this article, other complications of ocular trauma are listed in Box 5 . Box 5 Other complications of ocular injury Corneal erosion Hyphema ( Fig. 3 ) Iridodialysis ( Fig. 4 ) Cataract Lens luxation ( Fig. 5 ) Vitreous hemorrhage Commotio retinae Choroidal rupture Retinal breaks and detachment Traumatic optic neuropathy Optic nerve avulsion Fig. 3 Hyphema. Fig. 4 Iridodialysis. Fig. 5 Lens luxation. Eyelid lacerations Eyelid lacerations not involving the eyelid margin Although repair of eyelid lacerations that do not involve the eyelid margin may seem relatively straightforward, adequate knowledge of the anatomy and dynamic behavior of the eyelids is paramount to reduce the risk of complications. We recommend the following principles: Always confirm integrity of the globe: The eyelids are only thin protection of the globe. Therefore, an eyelid laceration should always prompt assessment of the globe’s integrity. Conservative wound debridement: Parts of the skin that are unviable can be removed by wound debridement; however, vascularization of the eyelids is excellent, so that debridement usually does not have to be performed aggressively. Moreover, remember that excessive debridement may lead to a relative skin deficiency, which may cause cicatricial ectropion or lagophthalmos. Free, relatively clean, avascularized flaps may be sutured back in their anatomic location. Do not close the orbital septum: The orbital septum is a sheet of fibrous tissue that extends from the orbital rims to fuse with the eyelid retractors. If the orbital septum is violated in an eyelid laceration, closing of the septal defect is not advisable, as this may lead to shortening of the septum. As the septum is a rigid structure firmly attached to the orbital rim, shortening may lead to a hang up of the eyelid causing lagophthalmos and exposure of the globe. Eyelid lacerations involving the eyelid margin It is important to understand that the eyelid margin is crucial for both functional and esthetic aspects of the eyelid and adequate restoration of eyelid margin is paramount. Various suture techniques have been described. For all techniques, good functional and esthetic results are obtained only if the following rules are followed: Protect the globe: Working closely to the ocular surface, it is advisable to protect the globe with either a protective shield or Jäger plate. Do not pass through the conjunctiva: In any technique for eyelid closure, care is taken not to breach the conjunctiva because the suture may cause irritation to the ocular surface, resulting in corneal abrasion or even ulcers. Also, place the knot anteriorly so that it does not erode through the conjunctiva. Mirror the sutures: The sutures are “mirrored,” both in an anterior-posterior and superior-inferior direction. This means that the height and depth of the suture should be exactly equal on both sides of the wound. If this is not done properly, a notch in the eyelid margin will result ( Fig. 6 ). Fig. 6 Laceration of the eyelid margin. ( A ) Traumatic laceration of the central inferior eyelid involving the eyelid margin. ( B ) Small notch after repair. If unsatisfied, try again: It is easier to obtain adequate eyelid position during the primary repair than to do so at a later stage. Therefore, if you feel that the wound margins do not approximate nicely, remove the sutures and try again. Timing: Primary closure of eyelid laceration is preferably performed within 24 hours, although we believe that good results can be obtained up to 48 hours. Most surgeons use a double-layered suture technique, which consists of deep tarsal sutures together with superficial skin sutures. Although many techniques are described, we usually use the following: Deep tarsal sutures ( Fig. 7 A): Just inferior to the eyelid margin, a Vicryl 6-0 or 5-0 suture is passed into the orbicularis muscle and out through the underlying tarsus. In the opposite wound edge, the suture is then passed through the tarsus and back out through the overlying orbicularis muscle. As noted previously, the height and depth of these passes should be exactly mirrored so that the wound edges approximate correctly. By pulling each end to the opposing side, you can confirm that the position of the suture is adequate. Now, before tying the first suture, a second suture is placed in a similar fashion just 2 to 3 mm inferiorly. If necessary, another third suture can be placed, again 2 to 3 mm inferiorly. The first suture is now tied. This often results in an angled apposition of the wound edges, which is corrected by tying the second and possibly third suture. Note that only 2 or 3 of these sutures are needed in the lower eyelid, whereas usually 3 or 4 are needed for closure of the upper eyelid, as it has a much higher tarsal plate. Fig. 7 Closure of an eyelid margin defect in 2 layers. ( A ) Placement of the deep tarsal sutures ( purple ) and eyelid margin suture ( blue ). ( B ) The eyelid margin suture is left long and tied down with the skin sutures. Eyelid margin suture ( Fig. 7 B): Although the deep tarsal sutures are the most important for reconstruction and integrity of the eyelid margin, a subtle indentation at the level of the gray line may remain. Therefore, some surgeons prefer to place an additional 6-0 or 7-0 fast-absorbing suture through the gray line. Because of its proximity to the ocular surface, this suture may cause irritation. To prevent this, the ends of the suture are usually left long and will be tied down with the skin sutures. Skin sutures (see Fig. 7 B): Either nonabsorbable sutures such as Prolene 6-0 or fast-absorbing sutures such as Vicryl Rapide 6-0 are used to close the skin. As mentioned, these sutures can be used to tie down the ends of the eyelid margin suture. Although variations of the previously mentioned double-layered suture technique have been used historically, a single-layered technique can give similar results : Single-layered suture for skin, orbicularis muscle and tarsus ( Fig. 8 A): Just inferior to the eyelid margin, a Prolene or Vicryl 6-0 is passed through skin and orbicularis muscle and exits through the underlying tarsus. In the opposing wound edge, the suture is then passed through the tarsus and back out through the overlying orbicularis muscle and skin. Again, before tying this suture, a second suture is placed in a similar manner 2 to 3 mm inferiorly. Fig. 8 Closure of an eyelid margin defect in one layer. ( A ) Single-layered suture for skin, orbicularis muscle, and tarsus. ( B ) An additional eyelid margin suture can be placed if needed, but is not shown here. Eyelid margin suture ( Fig. 8 B): If needed, an additional eyelid margin suture can be placed and tied down with the other sutures. Traumatic injury to the lacrimal drainage system Canalicular laceration Periocular trauma often causes horizontal traction on the eyelid. When this happens, the eyelid may rupture at its weakest points: the medial and/or lateral canthal ligaments ( Figs. 9 and 10 ). These ligaments connect the eyelid tarsi to the bony orbit. Fig. 9 Large eyelid laceration including the inferior canaliculus . ( A ) Eyelid laceration involving the lateral canthal ligament, medial canthal ligament, inferior canaliculus, and inferior fornix. The eyelid is now only vascularized through a small laterally based pedicle of skin and muscle. ( B ) Note the proximal end of the stent fixated inside the inferior punctum, whereas the distal end runs through the distal cut end and exits from the nose. ( C ) Note the triangle of darkened skin just inferior to the laceration, which is often wrongly chosen to be removed by excessive debridement. ( D ) One week after reconstruction. Note that the eyelid as a whole and the triangle of darkened tissue more specifically prove to be viable although it was vascularized only through the small laterally based pedicle. Fig. 10 Laceration of the medial and lateral canthal ligaments. ( A ) Eyelid laceration involving the medial and lateral canthal ligament in a child. ( B ) Three months after reconstruction of the lateral canthal ligament, medial canthal ligament, and inferior canaliculus. The lateral canthal ligament attaches to the lateral orbital tubercle (Whitnall tubercle), and avulsion of this ligament is relatively easily repaired, although a frequently made mistake is to reattach the lateral canthal ligament too far inferiorly, causing unsightly down slant of the eyelid. On the other hand, the medial canthal ligament has a more complex anatomy. It is composed of an anterior and a posterior limb that are attached to the anterior and posterior lacrimal crest, respectively. Although the posterior limb is more subtle, its patency is crucial for an adequate position of the eyelid, following the curvature of the globe posteriorly. More importantly, the medial canthal ligament has an intricate relationship with the lacrimal drainage system, which is why periocular trauma and eyelid lacerations are relatively often associated with canalicular laceration. Literature shows that canalicular repair must be performed if both canaliculi are involved ( Fig. 11 ); however, some investigators claim that in case of a single canalicular laceration, epiphora may not occur if one patent canaliculus remains. Even so, it must be said that if epiphora does occur, secondary repair of the canaliculus can be extremely challenging. Therefore, we advise to always attempt repair of the canaliculus as soon as possible but at least within 48 hours. Because of the complex anatomy and importance of primary repair, it is important that the canalicular reconstruction is performed only by surgeons experienced in lacrimal surgery. Fig. 11 Laceration after sharp trauma just medial to the medial canthal angle. Note the displacement and rounding of medial canthal angle, a sign that the medial canthal ligament has been cut. In this case, both inferior and superior canaliculi were lacerated and successfully reconstructed using 2 monocalicular stents. Advice in canalicular repair General anesthesia: Although small superficial lacerations may be reconstructed under local anesthesia ( Fig. 12 ), we advise general anesthesia for most cases. It provides a better controlled environment for the reconstruction, which at times can be challenging and frustrating. Moreover, local anesthesia results in additional tissue swelling, which may obscure the distal end of the cut canaliculus, especially when the rupture is near the lacrimal sac. Fig. 12 Obscured canalicular laceration. In periocular trauma, small canalicular lacerations may be easily overlooked. In this case, it appears to be only a superficial laceration of the lower eyelid; however, below the plug of mucus a laceration through the upper canaliculus was found on closer examination. Inspection of the punctum: The first step is to perform inspection of the punctum to see if it is still intact. In most cases, the laceration occurs a few millimeters medially to the punctum. Confirming laceration of the canaliculus: After stretching the punctum with a punctal dilator, a Bowman probe is inserted. Visualization of the probe within the wound confirms canalicular laceration. Identification of the distal end of the cut canaliculus: Although at times easily visible as a white “mouth” within the red and pink tissues, identifying the distal cut end of the canaliculus can be difficult. If the distal end cannot be found, one can try to irrigate the intact canaliculus with fluorescein, saline, or air. In addition, some advocate the use of pigtailed probes through the intact canaliculus, although we advise to use them cautiously, as they may cause iatrogenic damage to the intact canaliculus and lacrimal sac. Use a monocanalicular stent: In canalicular repair, it is paramount to place a temporary silicone stent. Traditionally, a bicanalicular stent is used, with one end advanced through the upper canaliculus and the other end through the lower canaliculus. These stents are then fixated inside the nose. We, however, recommend the use of a monocanalicular stent, as they have certain advantages. For one, it omits the need to stent the remaining intact canaliculus, reducing the risk of iatrogenic damage. Moreover, monocanalicular stents come with a plug at the proximal end that fits securely in the lacrimal punctum ( Fig. 13 ), reducing the risk of stretching the punctum and canaliculus (known as cheese wiring), as may be seen in the bicanalicular system. Monocanalicular stents come in 2 versions. One has a metal probe attached to the distal end of the stent, whereas the other has not. With this probe, it can be easier to engage the distal end of the lacerated canaliculus. The probe then has to be advanced through the nasolacrimal duct and retrieved from the nose, which may be difficult at times and may cause iatrogenic damage to duct and/or nasal mucosa. However, as the proximal end is fixed inside the punctum with the plug, it has the advantage that pulling on the stent now neatly approximates the proximal and distal ends of the cut canaliculus and medial canthal ligament ( Fig. 14 ). Not only does this aid in the repair of the canaliculus, but it also pulls the eyelid back into its original anatomic position, which may prevent postoperative structural abnormalities, such as medial ectropion ( Fig. 15 ). The advantage of a monocanalicular stent without a probe is that it does not have to be retrieved from the nose and can therefore be used under local anesthesia. Whichever stent is used, it is generally left in situ for approximately 2 to 3 months, unless ocular irritation or other complaints occur. Fig. 13 Monocanalicular stent. Postoperative result 3 months after reconstruction of an inferior canalicular laceration. Note the plate end of the stent inside the punctum. Fig. 14 Schematic representation of monocanalicular stent placement. ( A ) Laceration through the inferior canaliculus. ( B ) Placement of a monocanalicular stent. The proximal plate end sits securely inside the punctum, while the distal end is advanced through the lacrimal sac and nasolacrimal duct and is then retrieved from the nose. ( C ) Pulling on the distal end of the stent pulls the eyelid back into its anatomic position. Fig. 15 Medial ectropion. Result 2 weeks after unsuccessful reconstruction of eyelid laceration, including the inferior canaliculus and medial canthal tendon. Note the medial ectropion. Wound closure: After placement of a stent, 2 Vicryl 6-0 sutures are placed alongside the cut canaliculus. The canthal ligament can be reattached with Vicryl 5-0. The skin is closed with either nonabsorbable sutures, such as Prolene 6-0, or fast-absorbing sutures, such as Vicryl Rapide 6-0. Traumatic injury to the nasolacrimal duct Another frequent cause of epiphora after periocular trauma is obstruction of the nasolacrimal duct by fracture of the surrounding bones, such as may occur in naso-orbital-ethmoidal (NOE) fractures. Besides epiphora, obstruction of the nasolacrimal duct may lead to dacryocystitis. The obstruction in these cases may be treated by external or endonasal dacryocystorhinostomy at a later stage. Other signs of NOE fracture include epistaxis and cerebrospinal fluid leakage. As mentioned, the medial canthal ligament is attached to the bones that are involved in NOE fractures. Therefore, a displaced NOE fracture may also cause lateral displacement of the medial canthal tendon, a characteristic feature that is often overlooked at the initial assessment ( Fig. 16 ). Reconstruction of the fragments and/or the medial canthal tendon at primary trauma repair (preferably) may prevent this cosmetic problem. Fig. 16 Nasolacrimal duct obstruction in orbital fractures. ( A ) This patient was referred for epiphora and chronic discharge on the left side only. Patient history reported a head injury with blunt trauma to the left orbit approximately a year earlier, but no orbital imaging was performed at the emergency department of the referring hospital. Note that the left globe is displaced inferiorly, suggesting fracture of the orbital floor. Also note that the medial canthal angle is rounded and displaced laterally, which suggests NOE fracture. ( B ) Axial sections of CT imaging show a fracture of the medial orbital wall at the level of the nasolacrimal duct ( arrow ) and a fracture at the nasomaxillary suture ( arrowhead ). ( C ) Coronal sections of CT imaging show fractures of the orbital floor ( arrow ) and lateral wall ( arrowhead ). Acknowledgments The authors wish to thank Dion Paridaens, Willem van den Bosch, Tjeerd de Faber, and Mayke Gardeniers for their contributions in the figures. Disclosure The authors have nothing to disclose. References 1. Hayreh S.S., Kolder H.E., Weingeist T.A.: Central retinal artery occlusion and retinal tolerance time. Ophthalmology 1980; 87: pp. 75-78. 2. Chiang E., Bee C., Harris G.J., et. al.: Does delayed repair of eyelid lacerations compromise outcome?. Am J Emerg Med 2017; 35: pp. 1766-1767. 3. Van den Bosch W.A.: Praktische ooglidchirurgie.1997.Wetenschappelijke Uitgeverij BungeUtrecht 4. Verhoekx J.S., Soebhag R.K., Weijtens O., et. al.: A single- versus double-layered closure technique for full-thickness lower eyelid defects: a comparative study. Acta Ophthalmol 2016; 94: pp. 257-260. 5. Smit T.J., Mourits M.P.: Monocanalicular lesions: to reconstruct or not. Ophthalmology 1999; 106: pp. 1310-1312.

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