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PG Cor ner

Management of eyelid lacerations

ABSTRACT
Eyelid lacerations form a major bulk of the ocular trauma that we see in our casualty. These are managed differently depending on the depth,
width, and location of the injury. Repairing of eyelid injuries requires good anatomic knowledge and meticulous approach. This article gives a
brief overview of the practical aspects in managing an eyelid laceration.

Keywords: Canalicular tear, eyelid laceration, margin tear

INTRODUCTION Medial canthus and lateral canthus

Eyelids are protective curtains in front of eyes which give
shape and beauty to the face. Any defect or injury to eyelids
due to trauma or surgical excision needs to be meticulously
repaired for the best possible cosmetic outcome. Road traffic
accidents, blasts, and falls are the major causes resulting in
injuries to eyelids. Traumatic laceration to the eyelid requires
a thoughtful, well‑planned approach in order to provide
the best outcome and reduce the chances of postoperative
complications.
SURGICAL ANATOMY
Eyelid margin
Eyelid margin has a slightly rounded anterior edge and sharp
posterior edge. Anatomical structures in eyelid margin are
shown in Figure 1.
Gray line lies anterior to meibomian gland openings and
represents an avascular plane between the orbicularis and
the tarsal plate. It is the plane along which the lid can be
spilt into two halves.
Functional anatomy of the lid can be simplified by dividing
lid into two parts along gray line.
• Anterior lamella – eyelid skin and orbicularis muscle
• Posterior lamella – conjunctiva and tarsal plate.
F i b ro u s e x t e n s i o n f ro m t h e t a r s a l p l a t e f o r m s
the canthal tendons [Figure 2]. [1] Canthal tendons
maintain horizontal pull on the lids to maintain proper lid
apposition.
PREOPERATIVE EVALUATION
First and foremost is a detailed history regarding the time,
course, and circumstances of injury.
Rule out occult injuries
For full‑thickness upper eyelid injuries, never forget to check for
globe perforations. Globe injuries should be attended before
lid injuries. Eyelid trauma can be associated with hyphema,
angle recession, or retinal detachment. Detailed ocular
examination includes visual acuity, ocular movements,
intraocular pressure, pupillary reactions, and posterior
segment examination.
Clear watery discharge from one nostril indicates cerebrospinal
fluid rhinorrhea and is a red alert sign to look for anterior
skull base fractures.
Rita Mary Tomy
Oculoplasty and Neuroophthalmology Fellow, Little Flower
Hospital, Angamaly, Kerala, India
Address for correspondence: Dr. Rita Mary Tomy,
The Retreat, CN 203, Angamaly ‑ 683 572, Kerala, India.
E‑mail: ritamarytomy@gmail.com

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DOI:
10.4103/kjo.kjo_83_18 How to cite this article: Tomy RM. Management of eyelid lacerations.
Kerala J Ophthalmol 2018;30:222-7.

222 © 2018 Kerala Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

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Tomy: Management of eyelid lacerations
Wound inspection, cleaning, and documentation
We save all eyelid tissues, as high vascularity often allows for
viable re‑approximation of partially avulsed ocular adnexal
tissue [Figure 3]. We photograph all preoperative injuries and
immediate postoperative results.
A broad‑spectrum prophylactic antibiotic cover is
preferred (such as amoxicillin‑clavulanate or clindamycin
for the penicillin‑allergic). Tetanus prophylaxis may also be
required.
Tear outflow system
Blunt injury to the medial eyelid with resultant eyelid
laceration almost always tears the canaliculus. Telecanthus is
noted in case of outfracture of the lacrimal bone or laceration
of the medial canthal tendon. In eyelid lacerations medial
to the puncta, the canaliculi should be probed to assess
integrity [Figure 4]. We have found that most eyelid injuries
can wait 24–48 h for soft‑tissue swelling to improve.
Anesthesia
Most of our cases are operated under local anesthesia. Facial
block can be supplemented. We prefer general anesthesia
Figure 1: Eyelid margin anatomy (illustration by Christine Gralapp)
Figure 3: Avulsed eyelid laceration
Kerala Journal of Ophthalmology / Volume 30 / Issue 3 / September-December 2018
or deep monitored anesthesia care for complex lacerations
involving the canaliculi, underlying bone fractures, and when
operating on young children.
PRINCIPLES OF LID REPAIR
1. Wounds should be copiously irrigated and explored, with
the removal of any foreign material after local anesthesia
2. Reconstruction should be done in layers as per correct
anatomical orientation
3. Wounds should not be extended to explore structures
unless the exploration is for suspected foreign body
4. The orbital septum if damaged should never be repaired,
as this may result in compromised eyelid excursion
and even lagophthalmos. We should avoid suture
incorporation of the septum during repair
5. The presence of orbital fat raises the risk of deeper injury
and foreign bodies
6. In brow lacerations, eyebrows should never be shaved
off as orientation of the brow hair will help us in correct
approximation [Figure 5]
7. Anterior lamellar defects not involving lid margin should
be repaired by primary closure.[2] If required, undermining
of the surrounding skin was done to mobilize skin for
adequate closure. Interrupted sutures with 6‑0 vicryl
may allow for hematoma egress or infection drainage
Figure 2: Eyelids, deep dissection of structural elements
Figure 4: Probing to assess canalicular integrity in medial tears
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Tomy: Management of eyelid lacerations

8. We should repair deep tissues first. Posterior lamella (tarsus,

retractors, and conjunctiva) repair is dependent on the
extent of injury. Conjunctival lacerations of 5 mm or less
often do not need to be repaired unless there are apposing
lacerations of the bulbar and palpebral surface that may
adhere forming a symblepharon. We use 8‑0 vicryl suture
for larger conjunctival lacerations
9. Primary repair of the levator aponeurosis is done by Figure 5: Brow laceration pre‑ and postrepair
repositioning it to the upper half of the tarsus with
permanent 6‑0 or 7‑0 suture material.

Full‑thickness lid margin lacerations, canalicular tears, canthal

injuries, and lacerations with tissue loss are entities which
should be meticulously tackled using specialized techniques.

EYE LID MARGIN REPAIR

• The wound should be carefully inspected to identify

tarsus and lid margin landmarks such as gray line,
anterior lash line, and posterior margin
• Repair should be carried out preferably under operating Figure 6: Vertical mattress suture along the gray line
microscope.

“THREE‑SUTURE TECHNIQUE”

1. Vertical mattress suture along the gray line using 5‑0 silk
suture passed just like the traditional vertical (“far‑far
a b c
then near‑near”) mattress in line with the meibomian
Figure 7: (a) Eyelid marginal tear. (b) Tear repaired by three suture technique.
orifices [Figure 6]. A good apposition with slight margin
(c) After suture removal at 2 weeks
eversion should be the goal[3]
The tarsus is next closed with interrupted, partial‑thickness The avulsed lateral canthal tendon should be sutured or wired at
6‑0 vicryl sutures the tubercle so that it is 1–2 mm higher than the medial canthus.
2. Simple suture passed along the anterior lash line
3. Simple suture in the posterior mucocutaneous junction. The posterior limb of the medial canthal tendon is primarily
responsible for the medial canthal configuration. The
All suture ends are left long. The anterior lamella of the ruptured tendon can be sutured to the posterior lacrimal crest
eyelid is closed next, with interrupted sutures using or as posterior as possible taking special care not to injure the
5‑0 silk. The long end of the margin sutures is buried into lacrimal sac. The anterior head of the medial canthal tendon
the knots of these skin sutures to prevent the suture ends
can be sutured directly to its anterior lacrimal crest insertion.
from abrading the cornea [Figure 7a and b]. Sutures are
removed after 2 weeks [Figure 7c]. All tarsal irregularities
EYELID INJURIES WITH TISSUE LOSS
at the wound edges should be trimmed to allow good
tarsal‑to‑tarsal approximation which prevents tarsal buckling
These are very rare.
and postoperative notching of lid margin.

REPAIR OF CANTHAL INJURIES Full‑thickness eyelid defects with tissue loss are
classified depending on the horizontal extent of defect
The rounded configuration of the medial canthus and/or the into [4]
acute angle of the lateral canthus can be distorted or lost in
canthal injuries [Figure 8]. The integrity of the canthal tendon a. Small defects (<1/3)
is tested by grasping the lid with toothed forceps and pulling b. Medium defects (1/3–1/2)
toward the limbus.[3] c. Large defects (>1/2).

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Tomy: Management of eyelid lacerations

Repair of small defects (<1/3 of horizontal length)

Direct closure
This is possible because of increased eyelid laxity, especially
in older patients.

Lateral canthotomy and cantholysis

This provides additional horizontal lengthening in lateral
canthotomy, and horizontal limb of Y‑shaped lateral canthal
ligament is incised. For cantholysis, inferior or superior crus
of lateral canthal tendon is incised.

Repair of moderate defects (up to 1/2 of horizontal length)

Tenzel semicircular flap
It can be used for both upper lid and lower lid defects where
Figure 8: Lid laceration with medial canthal tendon injury
some tarsus remains on either side of the defect. A high
arched semicircular flap of the skin and orbicularis muscle is
rotated from lateral canthus after lateral cantholysis. The flap
dimensions are 22 mm × 18 mm (V × H). For upper lid defects,
the semicircle extends inferiorly, and for lower lid, the semicircle
extends superiorly. After undermining of the tissue, the lid is
pulled medially and direct lateral canthus is created [Figure 9].

Repair of large defects (>½ of horizontal length)

Cutler‑Beard bridge technique
Originally described for reconstruction of the upper lid, this
technique can be used for reconstruction of the lower lid defect
also, a procedure known as reverse Cutler‑Beard.

Cutler‑Beard procedure is done in two stages [Figure 10].

Figure 9: Tenzel semicircular flap
Hughes tarsoconjunctival flap technique
It is partial‑thickness posterior lamellar flap harvested from
upper lid to cover lower lid defects [Figure 11].

Mustarde cheek rotation flap

It is reserved for the reconstruction of very extensive
lower eyelid defects usually involving more than 75% of the
eyelid. The side of the triangle nearest the nose should be a b
practically vertical. The advantage of this procedure is that it
is a one‑stage, complete lower lid reconstruction [Figure 12].

REPAIR OF CANALICULAR LACERATION

Canalicular injury should be suspected in all lacerations which

are medial to the punctum [Figure 13]. All canalicular lacerations
should be repaired whether upper or lower under operating
microscope. Identification and retrieval of the proximal end of
canaliculus is the most difficult step. Methods used are:
• Examination under high magnification
• Gentle irrigation of fluid or air injection through
uninjured canalicular system
• Dyes such as methylene blue or diluted fluorescein can
also be used.
Kerala Journal of Ophthalmology / Volume 30 / Issue 3 / September-December 2018
c d
Figure 10: Cutler‑Beard procedure Stage 1: (a) Full thicknes upperlid defect.
(b) A three-sided inverted U-shaped incision is marked on the lower eyelid,
about 5 mm below lid margin. (c) By a full-thickness incision, the lower
lid flap is pulled under the bridge of lower lid and sutured in layers to the
upper lid defect. Since this flap is devoid of the tarsus, autogenous cartilage
from the ear can be used. Stage 2: (d) Separation of the flap at 6 weeks to
3 months. After cutting the flap, lid margin of newly formed upper eyelid
is sutured with conjunctiva covering the free margin.
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Tomy: Management of eyelid lacerations

a b

a b
Figure 11: (a) Upper lid is everted, incision is made through tarsus 4 mm
above lid margin, and flap is mobilized. (b) Flap is sutured with lower lid
tarsus to create posterior lamella. Sufficient skin to cover the anterior
surface of the flap is obtained by advancing a myocutaneous flap from
surrounding skin c
Figure 12: Mustarde cheek rotation flap. (a) A large myocutaneous cheek
flap is dissected and used in conjunction with an adequate mucosal lining
posteriorly. (b) A deep inverted triangle must be excised below the defect.
The side of the triangle nearest the nose should be practically vertical. (c)
Adequate rotation and suturing of the flapto cover the defect.

a b
Figure  14:  (a) Medial lower eyelid laceration with canalicular tear.
Figure 13: Parts of Mini‑Monoka monocanalicular stent (b) Canalicular tear repaired with Mini‑Monoka stent (blue arrow)

If proximal end is crushed and cannot be retrieved, eyelid At all follow‑up visits, meticulous chart documentation is
should be closed without further manipulation. critical, and supplemental photographic documentation is
desirable.
MATERIALS USED FOR CANALICULAR STENTING
COMPLICATIONS
1. Crawford bicanalicular stents
2. Mini‑Monoka monocanalicular stents 1. Lid margin notching
3. Angiocath I/V cannula 22 gauge. 2. Lagophthalmos
3. Hypertrophic scars
Mini‑Monoka monocanalicular stents are used in our hospital 4. Infections
with excellent postoperative results [Figures 13 and 14]. It 5. Tearing
has a self‑retaining cap which sits at the punctum giving it 6. Traumatic ptosis.
excellent stability and avoids extrusion or displacement of
stent. It also has the advantage of not disturbing the uninjured CONCLUSION
canaliculus. Only disadvantage is the high cost of stent.
Repairing of eyelid injuries is an art which requires good anatomic
FOLLOW‑UP knowledge and meticulous approach. Gentle tissue handling and
proper alignment should be done. The aim should be to achieve
Sutures are generally removed as follows: the best possible functional and cosmetic outcome. Always bear
• ‑ L o w ‑ t o ‑ m o d e r a t e t e n s i o n e y e l i d w o u n d s a t in mind that “Primary repair is the best repair.”
5–7 days
• ‑Marginal sutures at 2 weeks Financial support and sponsorship
• ‑Mini‑Monoka removal is done at 3 months. Nil.

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Tomy: Management of eyelid lacerations

Conflicts of interest 2. Vichare N. Management of lid lacerations ocular trauma. Delhi

There are no conflicts of interest. Ophthalmol Soc Times 2015;20:33‑8.
3. Nelson  CC. Management of eyelid trauma. Aust N Z J Ophthalmol
REFERENCES 1991;19:357‑63.
4. Carroll RP. Management of eyelid trauma. In: Hornblass A, editor. Oculoplastic
1. Dutton JJ. Atlas of Clinical and Surgical Orbital Anatomy. Orbital, and Reconstructive Surgery. Vol.  45. Baltimore: Williams &
Philadelphia: Saunders 1994:126. Wilkins; 1988. p. 409‑14.

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