REPAIR OF EYELID

LACERATION
DR. RASHMI JOSHI
DNB STUDENT
BCEIRC
OPHTHALMOLOGIC
EVALUATION
 Record visual acuity
 Pupils- RAPD
 Extraocular muscle movements –
diplopia +/-
 Assessment of orbital margin
 Documentation of globe projection
 Eyelid position
 Canalicular integrity
Intraocular injuries treated before eyelid repair

– Damage to intraocular
structures

– Enhanced exposure of the globe

REDUCE LID EDEMA

 Ice compresses
 Head elevation
 Corticosteroids
Goals of Eyelid Reconstruction

 Development of stable eyelid margin

 Adequate lid closure- globe protection
 Smooth, epithelialised internal surface
 To achieve acceptable aesthetic
results.
Principles of Eyelid
Reconstruction
 Reconstruct either anterior or posterior
eyelid lamella but not both with graft
 Maximize horizontal tension, Minimize
vertical tension
 Maintain sufficient and anatomical
canthal fixation
 Match like tissue to like tissue
Principles of Eyelid
Reconstruction contd…
 Narrow the defect as much as possible
before sizing the graft
 Incisions should follow RSTL
 Choose the simplest technique
 Minimize tissue distortion
 Maximize scar camouflage.
EYELID DEFECTS NOT
INVOLVING LID MARGIN
 Skin sutures only
 Presence of orbital fat in the wound !!
– Orbital septum
– Levator exploration
 Do not suture orbital septum
– Tether ptosis
– Upper lid lagophthalmos
EYELID DEFECTS
INVOLVING LID MARGIN
 Small - <33%
 Moderate – 33 – 50%
 Large - > 50%
 RECONSTRUCTIVE LADDER
FOR LOWER EYELID DEFECT
 <33% Primary closure+/- lateral
canthotomy
 33-50% Semicircular advancement or
rotation flap , Tarsoconjunctival
autografts
 >50%  Free tarsoconjunctival and
skin flap, Hughes flap, Mustarde flap.
 Other factors
PRIMARY CLOSURE
PENTAGON EXCISION WITH
LATERAL CANTHOLYSIS
PENTAGON EXCISION WITH
LATERAL CANTHOLYSIS
TENZEL SEMICIRCULAR FLAP
TENZEL SEMICIRCULAR FLAP
TENZEL SEMICIRCULAR FLAP
HUGHES PROCEDURE

 Tarsoconjunctival Flap for posterior

lamella
 Defects greater than 50%
 Vertical upper lid to lower lid sharing
 Anterior lamella reconstruction
–Advancement musculocutaneous flap
–Free skin graft
 Requires 2 stage procedure
nd
HUGHES PROCEDURE
HUGHES PROCEDURE
MUSTARDE FLAP

 Large rotational skin-muscle cheek flap

 Advantage –single stage procedure
– Monocular vision
– Children with amblyopia
– Active corneal disease
– Glaucoma
 Disadvantages –lacks orbicularis,
sagging
MUSTARDE FLAP
CANALICULAR TEAR
REPAIR
IDENTIFYING CUT END OF
THE CANALICULUS
 Direct visualization
 Identify and dilate the puncta and
probing of the proximal aspect of the
injured canaliculus
 Passing a pigtail probe into normal
canaliculus
 Injecting fluid or air into the normal
canaliculus while maintaining pressure
over the lacrimal sac
METHODS OF REPAIR
 Direct anastomosis of the
canalicular mucosa with 8-0
vicryl.
 Reapproximation of
pericanalicular tissue with a
larger suture
 Canalicular stents Mono,
bicanalicular stents
 Monocanalicular vs Bicanalicular

 Monocanalicular intubation:
 Avoids manipulation of normal canaliculus
and NLD (eliminating any possibility of
injury to them)
 Stents are easily placed (no intranasal
manipulation)
 May be placed using local anesthesia –
OPD procedure
 Monocanalicular vs
Bicanalicular

 Monocanalicular intubation (cont.):

 Easy to remove at the slit lamp
 No danger of “cheesewiring” or erosion
of punctum (occasionally occurs with
bicanalicular stents)
 No need for any knots or sutures – stent
is anchored at the punctum
 MINI MONOKA STENT

 For Canalicular Laceration or

Imperforate Nasolacrimal Duct
MINI MONOKA STENT

Photos compliments of Mark Brown, MD – EyePlastics.com

These photos show a canalicular laceration and

its repair with a Monoka monocanalicular stent.
MINI MONOKA STENT
MONOCANALICULAR SHUNTS-
DISADVANTAGES
 Spontaneously dislodge increasing
chances of postoperative-
– scarring,
– canalicular stenosis, or
– obstruction.
Ritleng Probe Procedure

The Ritleng Probe is backed out of the

Figure 1
lacrimal duct and separated from the
polypropylene thread-guide at its thinner
section (the light blue portion of the thread)
by sliding it out from the open slit that lines
the entire length of the probe.
Ritleng Probe Procedure

The thinner section of the thread-guide is

shown separating from the probe by sliding
Figure 2
out from the open slit.
Ritleng Probe Procedure

The Ritleng Probe is shown completely

separated from the thread-guide.
Figure 3
 Ritleng Probe Procedure

Photos compliments of Mark Brown, MD – EyePlastics.com

These photos show a canalicular laceration and its repair with a

monocanalicular stent using the Ritleng probe.
RECONSTRUCTIVE LADDER
FOR UPPER EYELID DEFECT
 <33% Primary closure +/- lateral
canthotomy
 33-50% Semicircular flap, Tarsal
sharing procedures
 >50%  Cutler Beard Procedure
 Other factors
SEMICIRCULAR ROTATION
FLAP
SLIDING TARSOCONJUNCTIVAL FLAP
PEDICLE FLAP FROM
LOWER LID
CUTLER BEARD- STAGE 1
CUTLER BEARD- STAGE 2
CUTLER BEARD- STAGE 2
LATERAL CANTHAL RECONSTRUCTION
LATERAL CANTHAL RECONSTRUCTION
MEDIAL CANTHAL RECONSTRUCTION
MEDIAL CANTHAL RECONSTRUCTION
MEDIAL CANTHAL RECONSTRUCTION
THANK YOU